Download Word

Heart/Cardiac Problem
Parent Information Form
Nash-Rocky Mount Public Schools
Student Health Services
School Year 20_____/20______
Student
Date of Birth
Parent/Legal Guardian
Grade
Contact #
Teacher
School_______
1. What age was your child diagnosed with a heart problem?
2. Who is your child’s doctor treating the heart problem?
Date of Last Visit____________________
 My child no longer sees a doctor for his/her heart problem.
3. What type of heart problem does your child have? (Check all that apply.)
___ Innocent/Benign/Flow Murmur – No medical intervention/care, medication, or limitation of activities.
___ Structural Murmur – May require medical intervention/care, antibiotics before dental procedures,
medication, and/or limitation of physical activity.
 Bicuspid Aortic Valve (click)
 Marfan Syndrome
 Mitral Valve Prolapse
 Mild Aortic Stenosis
 Mild Pulmonic Valve Stenosis
 Small Patent Ductus Arteriosus (PDA)
 Ventricular Septal Defect (VSD)
___ Irregular Rate or Rhythm
Supraventricular Tachycardia (SVT)
Other (specify)
 Bradycardia
___ Other Cardiac Condition (describe)
4. Does your child take antibiotics before seeing the dentist?  Yes  No
5. Does your child follow a special diet?  Yes  No
If yes, please describe
6. Does your child have activity limitations because of the heart problem?  Yes  No
If yes, please describe
7. Please list any other concerns you have for your child
Parent/Legal Guardian Signature
Date
To be completed by school nurse
Reviewed by
Date
_______
IHP sent _____Yes _____No
School Nurse Signature
File original in Individual Health Record.
Revised: June 2016