Kindergarten Health Assessment- NS KR

Kindergarten Health Assessment - NS KR

To be filled out by parent or guardian
I've already done this form...
Date

MonthDayYear
Date
Name of Child*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birthdate*

MonthDayYear
Date
Sex*

MaleFemale
Phone Number*

Area CodePhone Number
Email
example@example.com
Name of Person Filling out Questionnaire*

First NameLast Name
Relationship to Student*
Who is your child’s primary physician?*

First NameLast Name
Phone number*

Area CodePhone Number
When was your child’s last routine health exam?*

MonthDayYear
Date
Who is your child’s dentist?*

First NameLast Name
Phone Number*

Area CodePhone Number
When was your child’s last routine dental exam?*

MonthDayYear
Date
Pregnancy & Birth History: Any significant illnesses, accidents, or injuries during pregnancy? (i.e. premature labor, bed rest, bleeding or high blood pressure)

Birth History:*

Rows	Yes	No
Medications during pregnancy
Alcohol or drug use

Medications during pregnancy
Birth order*
Delivery*

VaginalC-Section
Complications:*
Fill out the information regarding your child’s birth history and development:
Birth Weight
Crawling
Talking
Length of Pregnancy
Walking
Toilet Trained

Check all that are concerns/problems:*

Rows	Yes	No
Bedwetting
Facial Twitches
Emotional Outbursts
Tantrums
Daydreams
Nail Biting
Head banging
Lack of Control
Difficulty with Coordination

Are there any major health problems in the family?*

YesNo
If yes, please list

Does your child have a medical diagnosis or health condition(s)?*

Rows	Yes	No
ADD/ADHD
□Allergies
□Asthma/Respiratory
□Diabetes
□Frequent ear infections
□Head Injury
Hearing issues
□Heart Condition
□Kidney/bladder issues
□Mental health issues
□Migraines
□Muscle/Bone/Joint
□Nosebleeds
Skin Rashes
□Seizures/ Neurological
□Stomach/Intestinal/ Bowel
□Vision issues
□Other

If other please describe*
If you checked any of the above, please list any medications, treatments, therapies, activityrestrictions, and/or medical equipment that will be needed in school:*
Is he/she still under treatment?*

YesNo
Has your child had any serious illness, operation, or injury? (i.e. fractures, stitches, head injuries, unconsciousness, etc.)*

YesNo
If yes please describe:
If yes, is he/she still under treatment?*

YesNo
Can school health services be helpful?*

YesNo
If yes, please comment:
Is your child on any prescription or over the counter medication, including inhalers?*

YesNo
If yes, please indicate medication(s)
Does it need to be given in school? If yes, please notify school nurse and request “Medication Permission” form. This is necessary even for over the counter medications!*

YesNo
Does your child have any allergies to food or medication?*

YesNo
If yes, what is the usual treatment required if exposed?
Does your child need special attention because of a disability? (i.e. visual, hearing, speech, or motor)*

YesNo
If yes, please comment:
Have special services been provided in the past?*

YesNo
If yes, please list where services were received(clinics, therapies, or agencies):
Preschool your child attended?*

HEALTH CONSENT & INFORMATION

** IMPORTANT - Please Read Carefully **
Parents/Guardians are expected to transport their student home or to the doctor/hospital when ill. In case of serious illness or injury, all emergency numbers provided to Swink School will be called. If parent/guardian/emergency contacts cannot be reached, school personnel will immediately call 911 and request emergency health personnel to arrange for transporting the student to an emergency facility.

If medication is to be taken at school, a completed Permission for Medication Form must be on file in the Health Office before it can be given. This includes all prescription medications, as well as over-the-counter and herbal remedies. All medications MUST be kept in the Health Office. Exceptions may be granted on a case-by-case basis with approval only, please contact the school nurse for more information.

Occasionally, your child may need sunscreen during a school day. For those occasions, we must have written parental permission for your child to use sunscreen. I give my child permission to use the sunscreen I have provided for them when it is needed during school activities
Sunscreen*

YesNo
The Swink School nurse accesses the Colorado Immunization Information System (CIIS), a confidential web-based system that collects and consolidates immunization information for disease control purposes. The Swink School health office uses CIIS as a tool to ensure that your child has the proper immunizations required for school. This includes entering immunization data that the school has on file in a student’s health record which may not be listed on CIIS. If you do not want your child’s immunization data to be entered on CIIS, you may choose to opt out by notifying the school nurse in writing at the beginning of the school year.
I give permission for my child to be screened for Hearing, Vision, Height and Weight*

YesNo
I have read and understand the above information, and can get more information about Swink School health policies in the Student Handbook, on the school website, or by contacting the school nurse. I give permission for the health information contained on this Health Information Card, to be shared with adults in the school setting who will be working with my child, on a need to know basis. It is the responsibility of the parent/guardian to notify the school nurse whenever there is any change in the student's health status or care.
Date

MonthDayYear
Date
Parent/guardian Name*

First NameLast Name
Parent/Guardian Signature*
Should be Empty:

Kindergarten Health Assessment - NS KR

HEALTH CONSENT & INFORMATION