Student Health Form
Please fill this out for EACH student in Taft District 90.
Student Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Grade Level
*
Please Select
K
1
2
3
4
5
6
7
8
Doctor's Name
*
First Name
Last Name
Doctor's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Dentist's Name
*
First Name
Last Name
Dentist's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Eye Doctor's Name
*
First Name
Last Name
Eye Doctor's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Physical Exam Upload
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Dental Exam Upload
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Eye Exam Upload
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Does this student have ALLERGIES to food, insects, or medication?
*
Yes
No
Please list all allergies / reactions.
*
Does this student have SEASONAL ALLERGIES?
*
Yes
No
Does this student use an EpiPen?
*
Yes
No
Does your student have asthma?
*
Yes
No
Does your student need an inhaler?
*
Yes
No
How often does this student use an Inhaler?
*
Rarely
Once daily
More than once daily
For sports
Will this student use an Inhaler while at school?
*
Yes
No
If your student uses an inhaler, please upload a medical authorization for the inhaler.
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Does this student take (or will need to take) daily medicine?
*
Yes
No
Will this medicine need to be taken while at school?
*
Yes
No
Please list all medications / doses / times/ and what it's for. (Please note that if your child will be taking medication at school, whether prescription or over-the-counter, a doctor's authorization note is required.)
*
Does your student wake during the night coughing?
Yes
No
Is there anything else we should know about this condition?
Does your student have birth defects?
Yes
No
Is there anything else we should know about this condition?
Does your student have a developmental delay?
Yes
No
Is there anything else we should know about this condition?
Does this student have blood disorders? Hemophilia, Sickle Cell, Other?
Yes
No
Is there anything else we should know about this condition?
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Does this student have diabetes?
Yes
No
Is there anything else we should know about this condition?
Does this student have a head injury / concussion / passing out?
Yes
No
Is there anything else we should know about this condition?
Does this student have seizures?
Yes
No
What are the seizures like / how often do they occur?
Does this student have heart murmurs or shortness of breath?
Yes
No
What else should we know about this condition?
Does this student have dizziness or chest pain during exercise?
Yes
No
What else should we know about this condition?
Does this student have bone or joint problems, injuries, scoliosis, etc?
Yes
No
What else should we know about this condition?
Has this student ever had a serious medical condition, injury, illness, or other event that required hospitalization?
Yes
No
Please list / describe hospitalizations and surgeries (when, what for, etc.)
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Does this student wear glasses or contacts?
Yes
No
What else should we know about this condition?
Does this student have other vision problems?
Yes
No
Please explain:
Does this student have ear or hearing problems?
Yes
No
Please explain:
Does this student have dental problems?
Yes
No
Please explain:
Does this student have dental braces?
Yes
No
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Does your child have any restrictions at school?
Yes
No
Please indicate / list those restrictions. (A physician's note will be required.)
By submitting this form, you certify that all of the information provided to Taft District 90 is truthful to the best of your knowledge, and agree that your electronic signature is the legal equivalent of your physical signature. Use your mouse (or finger on a touch screen device) to electronically sign your health information form.
*
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