REG STRATION—WAYOATA ELEMENTARY SCHOOL - Retsd.mb.ca
REG STRATION—WAYOATA ELEMENTARY SCHOOL - Retsd.mb.ca
REG STRATION—WAYOATA ELEMENTARY SCHOOL - Retsd.mb.ca
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hashastrachealoral/nasal<strong>REG</strong> ISTRATIO N—WAYOATA <strong>ELEMENTARY</strong> SCH001Medi<strong>ca</strong>l QuestionnairePlease complete the following (Specify yes if physician-diagnosed)1. Anaphylaxis Yes LI No LI2. Anaphylaxis —EpiPen prescribed Yes LI No LI3. Asthma YesLI NoD4. Asthma —inhaler prescribed Yes LI No LI5. Bleeding(i.e. hemophilia, Von Willebrand disease)YesONoD6. Cardiac condition Yes LI No C7. Catheterization Yes LI No LI8. Central line Yes El No 09. Diabetes Yes LI No LI10. Gastrostomy Yes LI No LI11. Intermittent <strong>ca</strong>theterization Yes LI No LI12. Medi<strong>ca</strong>tion Yes LI No LI13. Nasogastric tube Yes LI No LI14.Osteogenesisimperfecta YesLI NoD15. Ostomy Yes LI No LI16. Other intervention Yes LI No LI17. Oxygen YesO NoD18. Seizure disorder Yes LI No LI19. Steroid dependence Yes LI No LI20. Suctioning (A) —21. Suctioning (B) —suctioning Yes LI No 0suctioning Yes LI No LI22. Tracheostomy Yes LI No LI23. Ventilator Yes LI No 0This medi<strong>ca</strong>l information is being collected so that appropriate health-<strong>ca</strong>re plans may be developed and may benecessary to obtain funding. This information will only be shared with appropriate individuals. This information isprotected by The Personal Health Information Act. Questions should be directed to the school principal.Page 3 of 4 I Tyler SIS 12/2012,:--RiverEastTranscona<strong>SCHOOL</strong> V VISION
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