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Get UT UDOH IHP104.1 2017-2023

UCA 26-41-104 Utah Department of Health STUDENT INFORMATION Asthma: Yes (if yes, high risk for severe reaction, please also complete IHP101.1 form) No Student: DOB: School: Parent: Phone: Email: Physician: Phone: Fax or email: School Nurse: School Phone: Fax or email: Grade: EXTREMELY REACTIVE TO THE FOLLOWING: Allergen(s): If checked, give epinephrine immediately if the allergen was LIKELY eaten, for ANY symptoms. If checked, give epinephrine immediately if the allergen was.

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