344 W. Cherry St, Ste.

B
Alma, AR 72921
479-380-5724
Child’s Name:

1. Does the student have a physical impairment or health condition?

2. If yes, please state the nature of the impairment or health condition.

☐Headaches ☐Difficulty Concentrating ☐Discomfort ☐Drowsiness ☐Dizziness
☐Shortness of Breath ☐Loss of appetite ☐Muscle Pain ☐Respiratory Distress
☐Allergies ☐Nausea ☐Weakness ☐Abdominal Pain ☐Chest Tightness ☐Asthma
☐Accelerated Respiration ☐Hypoxia (Reduction of Oxygen) ☐Depression
☐Anxiety ☐Neck Pain ☐Back Pain

3. Also, if yes, does a mask impact the impairment or health condition? If so, how?

4. Is the student currently under the care of the provider, and if so, for how long?
______________________has been under my care since ________________________. Their
health condition is directly associated with prolonged mask exposure. Removing the
mask is the treatment that is required. .

It is illegal to mandate EUA products under Title 21 U.S.C. § 360bbb-3(e)(1)(A)(ii)(I-III) of

the Federal Food, Drug, and Cosmetic Act (FD&C Act) which states:

individuals to whom the product (face mask) is administered are informed—

(I) that the Secretary has authorized the emergency use of the product;

(II) of the significant known and potential benefits and risks of such use, and of the
extent to which such benefits and risks are unknown; and

(III) of the option to accept or refuse administration of the product, of the

consequences, if any, of refusing administration of the product, and of the alternatives to
the product that are available and of their benefits and risks.

Mask EUA documentation can be found on the FDA’s website: https://www.fda.gov/medical-

devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/
personal-protective-equipment-euas#barrier

James W. Smith, DC