CYSTIC FIBROSIS MEDICAL MANAGEMENT PLAN
(MUST be FILLED OUT COMPLETELY by PHYSICIAN/HEALTHCARE PROVIDER)
Name: _______________________________ D.O.B._________________ School Yr._____________
PLACE
Grade: __________ Teacher: _________________________________________________________
Parent: ___________________________________Primary Phone # __________________________
I.D.
PHOTO
Physician: __________________________________ Phone # ________________________________
Symptoms:
persistent coughing, at times with mucus  fatigue
Upset stomach
 recurrent respiratory infections
 wheezing or shortness of breath
HERE
 smaller stature
Medications taken at home: _____________________________________________________________________________
____________________________________________________________________________________________________
Medications Needed at School:
Yes
 No _________________________________________________________
Enzymes Needed at School:
Yes
 No
Enzyme Brand Name _____________________________________
# to be taken with snacks _________________________ # to be taken with meals __________________________________
For Self Administration of Enzymes:
 It is my professional opinion that _____________________________
Special Equipment Needed at School
 Yes
should
should NOT carry and use
the enzymes by him/herself.
 No ________________________________________________________
(Parent must provide any special equipment needed while child is at school)
Dietary Modifications: ____________________________________________________________________________________
_____________________________________________________________________________________
Activity restrictions (excuse from physical education program will require a doctor’s note): ___________
_____________________________________________________________________________________
Fluids needed with physical activity
_________________________
Yes
No
What type is needed?
Other modifications needed (i.e. frequent bathroom breaks):___________________________________
_____________________________________________________________________________________
Authorization for Health Care Provider and School Nurse to Share Information:
I authorize my child’s school nurse to assess my child as regards his/her special health care needs and to discuss
those needs with my child’s physician as needed throughout the school year. I understand this is for the
purpose of generating a health care plan for my child. I understand I may withdraw this authorization at
any time and that this authorization must be renewed annually.
Parent/Guardian Signature _____________________________________________ Date _____________
Doctor’s Signature ________________________________ Date _______
Signature below indicates that the plan is reviewed and appropriate documentation is complete.
School Nurse Signature ________________________Date ____________
CYS1