Student Health History and Updates

Student Health History and Updates

2020/2021
Student Name *

First Name Last Name
DOB *

Month Day Year
This information will be shared with staff and administration on a need to know basis, and with emergency medical staff in the case of an emergency, unless you notify us otherwise.
Please check if your child has had difficulty with any of the following. Please explain under “Comments": *

ADD/ADHD Asthma/Respiratory Bleeding Bone/Spine Bowel/Bladder Emotional/Behavior Diabetes Chicken Pox Hearing/Ears Heart Infections Kidney Physical Disability Seizures Skin Vision/Eyes
Comments:
1. Does your child have allergies to: *

Medicines Food Insect Latex Dust/Mold No Known Allergies
What?:
What Happens?
Treatment?
A Food Allergy Action Plan completed by a licensed healthcare provider is required for all students with food allergies.

An Asthma Action Plan completed by a licensed healthcare provider is required for all students diagnosed with asthma.
2. Has your child had any illnesses since school ended in March 2020?: *

Yes No
3. Has your child had any immunizations since school ended in June? *

Yes No
4. Is your child being treated or evaluated for any health conditions: *

Yes No
5. Has your child ever been examined by an Eye Doctor? *

Yes No
Date of last exam

Month Day Year
Date
Glasses Prescribed? *

Yes No
6. Has your child had any emotional upsets since school ended in June? *

Yes No
7. What is the date of his/her last dental exam? *

Month Day Year
Date
8. What is the date of his/her last physical exam? *

Month Day Year
Date
9. Does your child need to take any medications/treatments during the school day? *

Yes* No
*If yes, please contact the school nurse to make arrangements and complete appropriate consent form/s.
Parent/Guardian Signature

Clear
Date

Month Day Year
Date
Should be Empty: