Background: To educate children with chronic diseases in the least restrictive environment, schools must prevent, recognize, and react appropriately to symptom exacerbations. Schools are often pushed to their limits of knowledge, resources, and comfort level. This study determined the health conditions of students for whom districts seek school physician consultation and the nature of school physician consultants' involvement. Methods: A retrospective record review was performed on 250 of the most recent records of school-elicited referrals from an academic center that provides physician consultation to school districts. Referrals were sent from 8 school districts in southern California (July 1996 to October 2006). Data collected were nature of student's special health need, the school physician consultant's intervention required to satisfy schools' needs, student grade level, enrollment in special education, and health-related excessive absenteeism. Results: No single chronic condition, symptom, or special health care need predominated. Six types of school physician consultant activities were used to overcome hurdles schools faced when accommodating students with special health care needs. The 3 most common were direct communication with students' own physicians (70% of students), recommending an appropriate level of school health services when this was a matter of controversy (42%), and formulating portions of students' individualized school health plans (38%). Conclusions: A portion of students with special health care needs benefited from district referral to a school physician consultant. Whether some of these referrals can be avoided if school personnel and students' own physicians are supported and trained to communicate more effectively with one another needs to be explored. (Contains 3 tables.)