Sample Fainting Episode Form
The Fainting Episode Form must be completed by the student’s parent/guardian and returned to the school administrator/designate.
Name of Student:
Name of Teacher:
As a result of a fainting episode, my child was seen by a medical doctor.
Results of Medical Examination
My child/ward has been examined by a doctor who determined that a cardiac assessment was not necessary or required.
My child/ward has been examined by a doctor. A cardiac assessment was completed, and no rhythm disorders were diagnosed. My child/ward may resume full participation in physical activity with no restrictions.
My child/ward has been examined by a doctor. A cardiac assessment was completed, and a rhythm disorder was diagnosed. My child/ward therefore must begin a medically supervised return to physical activity plan. Refer to comments below and/or attached physician’s information.
Parent/Guardian signature:
Date:
Comments:
Physician’s input attached:
Yes
No