Student Health Entrance Form 2024-25

Student Health Entrance Form

2024-25 School Year
Name of Parent/Guardian Completing This Form*

First NameLast Name
Parent/Guardian Email*
example@example.com
Student Name*

First NameLast Name
Student Date of Birth*

MonthDayYear
Date
Student Health Questionnaire

Please indicate any and all known allergies for this student. *

	Yes	No
Food Allergy
Medication Allergy
Environmental Allergy
Insect Allergy
Other Allergy (please describe in box below)

If you answered "Yes" to the above, please provide more allergy details below.

Please indicate if your student has any of the general health concerns or conditions listed below. *

	Yes	No
Bladder/Bowel Condition
Bleeding Condition
Diabetes
Digestive/Stomach Condition
Head Injury / History of Concussion
Headaches (including Migraine)
Immune System Condition
Muscle / Orthopedic Issues
Nutritional / Growth Issues
Speech Issues

If you answered "Yes" to any of the above general health concerns, please provide more general health condition details below.
Does the student have any behavioral or cognitive health conditions or concerns?*

Yes.No.Unsure.

If you answered "Yes" to the any of the behavioral or cognitive health concerns above, please provide more details below.
Does the student have any respiratory/breathing health conditions or concerns?*

Yes.No.Unsure.

If you answered "Yes" to any of the respiratory health concerns above, please provide more details below. Please include any medication (including inhalers) required.
Does the student have any neurological health conditions or concerns?*

Yes.No.Unsure.

If you answered "Yes" to any of the neurological health concerns above, please provide more details below. Please include any medication (including inhalers) required.

Please indicate if your student has any of the vision or hearing conditions listed below. *

	Yes	No
Glasses/Contacts Worn
Hearing Aids Worn
Hearing Loss

Is preferential seating due to vision or hearing concerns required?
Please provide more details about your student's vision or hearing condition(s) below.
Does this student have any other health conditions not covered in any section above (including activity restrictions or dietary restrictions)?*

Yes.No.
Please provide more details about your student's other health condition(s) or activity/dietary restrictions.
Would you like to discuss any confidential health information with the AXIS school nurse?*

Yes, please.No, thank you.
Your request has been forwarded to the AXIS School Nurse.
Student Medications
Please list all prescription, over-the-counter, and herbal medications your child takes regularly:*
If none, please simply write N/A or None.
Will the student need any medication administered during the school day at any time?*
Students who require any medication to be administered during school hours, will require a Medication Administration Form. You will automatically receive an email with a link to the Medication Administration Form after submitting this health form.

Student Medical Provider Information
Student's Primary Care Provider (Physician, PA, NP) Name*
e.g. Dr. Daniel Tiger
Primary Care Provider Phone Number*
Please enter a valid phone number.
Primary Care Provider Office Address*

Street Address

Street Address Line 2

CityState

Zip Code
Student's Dentist Name*
Dentist Phone Number*
Please enter a valid phone number.
Dental Office Address*

Street Address

Street Address Line 2

CityState

Zip Code
Consents & Disclosures
Emergency Treatment & Transport Policy
By initialling I indicate that I have read and accept the emergency treatment and transport policy.*
I give permission for AXIS staff to call a doctor, ambulance, hospital, or for a member of staff to transport my child should a medical emergency arise.

It is understood that a conscious effort will be made to contact me before any action is taken, but if not possible the expense of the medical care will be accepted by me, student's parent / guardian.
Parent/Guardian Responsibility to Update Medical Information Policy
By initialling I indicate that I have read and accept the responsibility to update medical information policy.*
I acknolwedge that it is my responsibility as a parent/guardian of this student to update AXIS International Academy of any changes in my student's health or medications throughout the school year.

Updating information can be done by emailing the AXIS Health Office, healthoffice@axiscolorado.org.
Disclosure of Student Medication Policy
By initialling I indicate that I have read and accept the disclosure of student medication policy.*
Parents/Guardians must make the school nurse/staff aware of any and all medications that the student brings on to campus.

Self-carry medications and proper medication administration must be discussed with the school nurse. Under no circumstances, may a student self-carry or self-administer medication without the knowledge and approval of the school nurse.
By signing my name in the box below, I acknowledge that I have voluntarily provided this health information to AXIS International Academy and understand that it is confidential and is only shared with staff on a need to know basis.

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Should be Empty:

	Yes	No
Anxiety
Autism/Asperger's
Bipolar
Depression
Behavior issues
Eating Disorder Issue
ADD/ADHD
Developmental Delay
Other Behavioral/Cognitive Condition (please explain in box below)

	Yes	No
Asthma
Cystic Fibrosis
Other Respiratory Condition or Breathing Issue (please explain in box below)

	Yes	No
Cerebral Palsy
Seizures
Other Neurological Condition (please explain in box below)

Student Health Entrance Form

Student Health Questionnaire

Student Medications

Student Medical Provider Information

Consents & Disclosures