Medical Forms

Meet our friendly and knowledgeable School Nurse - Ms Ambria!

Picture of school nurse ms ambria
Ms Ambria Susmena
Patoka School Nurse
618-432-5440, Ext. 306
asusmena@patokaschool.com



To access form, click on the name below and print.  If at any time there are questions on one of the medical forms, please contact our School Nurse.

2020-2021 School Year Medical Requirements - TBD

Kindergarten Medical Forms - print out, complete and bring to registration

School Physical Form

Sports Physical Form

Vision Exam Form


Dental Exam Form


Food Allergy Form

Lead Risk Assessment Form

Medication Order Form

P.E. Excuse Form


Authorization for Exchange of Confidential Information Form

Patoka School's Concussion Protocol

Concussion Symptom Checklist Form

When to Keep your Child at Home!  Fact Sheet


Checklist for Eliminating Headlice
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