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Get Chronic Illness Form 2013-2024

Twin Rivers Unified School District Student Services Dept. Child Welfare Attendance 916 566-1615 CHRONIC ILLNESS VERIFICATION FORM Student Forward to. DOB / Grade School Name School Fax Number Dear Physician Your patient is a student enrolled in Twin Rivers Unified School District. For our records please list the chronic illness diagnosed for the student Please check or list symptoms that would not warrant an office visit but might require the child to stay home from school* This will allow the parent to verify illnesses by listing in writing to the school the symptoms designated below without bringing the child to your office for an examination* This document expires at the end of the academic year it was received* / / This section must be Physician signature date completed by Physician An attached business card or letterhead is required Chronic Illness/Medical Diagnosis Symptom s Expected frequency. of episodes and length of absence per episode examples monthly 4 times per school year etc* Neurological system Lethargy dizziness/unsteadiness numbness in extremities petit mal seizures grand mal seizures severe headache blurred vision Integumentary system skin lesions infections edema Musculoskeletal system pain inflammation/swelling Respiratory system weakness/fatigue pallor/cyanosis continual coughing congested airway difficulty breathing Cardiovascular system weakness/dizziness palpitations rapid pulse arrhythmia fevers/infections. day s. Gastrointestinal system nausea/vomiting diarrhea constipation abdominal pain Genitourinary system bladder/kidney infection fever Ear Nose Throat chronic infections severe allergies severe asthma pneumonia/bronchitis Additional Comments --------------------------------------------------------------------------------------------------------------------------------To Physician s name address Parent/ I hereby request and authorize the exchange of information on the above diagnosis pertaining to my child between Health Services/Student Support Services designated staff of the Twin Rivers Unified School District and Physician s Name. Guardian I request Twin Rivers Unified School District to contact the parent/guardian signing this Authorization for Exchange will only be made if the frequency or length of absences exceeds the numbers authorized above. I of Information further understand with this verification I must submit written explanations to verify each absence. Parent/Guardian Signature. Date /. Boxed areas and appropriate symptoms must be filled in for form to be valid* Revised 3/13. DOB / Grade School Name School Fax Number Dear Physician Your patient is a student enrolled in Twin Rivers Unified School District. For our records please list the chronic illness diagnosed for the student Please check or list symptoms that would not warrant an office visit but might require the child to stay home from school* This will allow the parent to verify illnesses by listing in writing to the school the symptoms designated below without bringing the child to your office for an examination* This document expires at the end of the academic year it was received* / / This section must be Physician signature date completed by Physician An attached business card or letterhead is required Chronic Illness/Medical Diagnosis Symptom s Expected frequency.

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