Health Assessment Record

ALABAMA STATE DEPARTMENT OF EDUCATION

HEALTH ASSESSMENT RECORD
To Parent or Guardian:

The purpose of this form is to provide the school nurse with additional information regarding your child's health needs. The school nurse may contact you for further information. The information requested is essential for the school nurse to meet the health needs of your child.

This information will be kept confidential.
School Year
Name of Student

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Date
Sex
School
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Telephone Number
Cell Phone Number
Additional Phone Number
Grade
Teacher/Homeroom
Transportation

Bus RiderCar RiderSpecial Needs BusAfter School
Name of Parent/Guardian

First NameMiddle NameLast Name
Work Number

Part III - Medical History
Known Health Problems*

NoYes
If NO, go directly to the bottom of the page and provide a parent/guardian signature.
If YES, and diagnosed by a physician, answer each question below.
Attention Deficit Disorder (ADD)

YesNo
Attention Deficit Hyperactivity Disorder (ADHD)

YesNo
Allergies

YesNo

	Yes	Description
Activity Restrictions
Medications taken at home

ALABAMA STATE DEPARTMENT OF EDUCATION