Medical Forms

Back-to-School Health Checklist

This form helps to remind parents and guardians about the health forms due to the school at the beginning of each school year. (This checklist does not need to be returned to the school.)

Back-to-School Health Checklist

Health Service Form

This form is provided for your physician to use to document your child’s annual physical.  Many physician offices have their own forms and these are accepted as well.  All students participating in sports sponsored by Ladue Schools must have an annual physical.

Health Service Form

Kindergarten Lead Screening Form

This form is recommended by the Saint Louis County Health Department to be filled out by the primary care physician to determine whether or not the student has been exposed to lead. Exposure to lead may contribute to childhood developmental delays and learning difficulties in school. It is strongly encouraged that all students entering kindergarten be screened for lead poisoning. This form is to be returned to your child’s elementary school and will be forwarded to the Saint Louis County Health Department.

Kindergarten Lead Screening Form

Medication Administration Form

This form must be completed by the physician and the parent/guardian if a child needs to receive medication at school.  The doctor must order the medication and the parent/guardian must give the school consent to administer the medication.

Medication Administration Form

Request for Self-Administration of Medication Form

This form is to be completed by the physician, parent/guardian and student.  It is a supplement to the Medication Administration Form and allows students who require medication for life-threatening illnesses to carry and administer their own medications (i.e., EpiPens, inhalers, and diabetic supplies).

Request for Self-Administration of Medication Form

Pre-Participation Physical Evaluation for Athletics Form (MSHAA)

This form is required by the Missouri State High School Activities Association (MSHAA) to certify that each student participating in athletics is deemed physically able to participate in sports by a physician or advanced practice healthcare provider.  It must be submitted annually to play sports.

Physical Evaluation for Athletics (MSHAA) Form

Release of Information Form

This form notifies physicians that you have given consent for them to communicate with appropriate Ladue Schools personnel.

Release of Information Form

Allergy Action Plan

Students who have a history of a severe allergic reaction and a diagnosis of a life threatening allergy should have an Allergy Action Plan on file with the school nurse. This form is filled out by the student’s physician and communicates the doctor’s orders for medical intervention specific to the student in the event of an allergic reaction.

Allergy Action Plan

Asthma Action Plan

Students who have asthma and need to use an inhaler at school should have an asthma action plan that provides instructions for treatment at school in the event of an asthma attack or exacerbation of symptoms. This form needs to be filled out by the student’s physician.

Asthma Action Plan

Diabetes Medical Management Plan (DMMP)

Students who have a history of diabetes should have a Diabetes Medical Management Plan on file with the school nurse. This form is filled out by the student’s physician and communicates the doctor’s orders for medical intervention specific to the student for diabetes management while at school.

Diabetes Medical Management Plan

Seizure Action Plan

Students who have a history of seizures should have a Seizure Action Plan on file with the school nurse. This form is filled out by the student’s physician and communicates the doctor’s orders for medical intervention specific to the student in the event of a seizure at school.

Seizure Action Plan

Student Health Assessment

This form is to be completed annually to inform the school nurse of your child’s medical history and any current diagnoses.  It also gives the district consent to seek medical treatment in the event of an emergency and provides information on how to reach your child’s physician.

Student Health Assessment