STUDENT HEALTH HISTORY UPDATE 25-26

Student Health History Update
Student's Name

First NameLast Name
Student Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
DOB

MonthDayYear
Date
Grade:
Teacher
Mother/Guardian's Name

First NameLast Name
Mother/Guardian's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number

Area CodePhone Number
Home Number

Area CodePhone Number
Work Number

Area CodePhone Number
Email
example@example.com
Father/Guardian's Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number

Area CodePhone Number
Home Phone Number

Area CodePhone Number
Work Phone Number

Area CodePhone Number
Email
example@example.com
Emergency contact if parents/guardians cannot be reached and are allowed to pick-up your child from school (Photo ID will be required) Please provide daytime phone numbers.
Name

First NameLast Name
Phone Number

Area CodePhone Number
Relationship
Family Physician

First NameLast Name
Phone Number

Area CodePhone Number
Medical Insurance
Group #
1. PLEASE CHECK IF CHILD HAS HAD DIFFICULTY WITH ANY OF THE FOLLOWING. GIVE DATES AND ADDITIONAL INFORMATION UNDER COMMENTS.
Comment:
please explain other
2. Does your child have allergies to medicine, food, latex or insect bites?
To What?
What Happens?
Treatment(s)?
3. Has your child had any illnesses since school last ended?
a. Types of illness with date(s)?
4. Has your child had surgery since school last ended?
a. Types of surgery with date(s)?
5. Has your child received any immunizations since school last ended?
a. Types of immunization with date(s)?
6. Is your child being treated or evaluated for any health conditions?
List condition(s):
7. Is your child on any medication or treatment?
Name medication and or treatment(s):
7a. Does your child need medicine during school hours?
11. Has your child experienced any major life events, such as a recent move, death, separation, divorce, etc. since the end of last school year?
12. Have you, your child or anyone in your household tested positive for COVID-19?
What is the date of his/her last physical exam?

MonthDayYear
Date of exam?

MonthDayYear
Family Eye Physician/Optometrist

First NameLast Name
Phone Number

Area CodePhone Number
8. Has your child ever been examined by an eye doctor?
Glasses provided?
If your child wears glasses or contact lenses, when was the prescription last changed?

MonthDayYear
Family Dentist

First NameLast Name
Phone Number

Area CodePhone Number
9. What is the name of your child's dentist?
a. What is the date of his/her last dental exam?

MonthDayYear
I give permission for my child to have the medication/s "Checked" below as determined by the nurse
Signature
Today's Date

MonthDayYear
I verify that all of the above information is correct.This information may be shared on a “need to know” basis with school personnel and emergency medical staff.
Should be Empty:

Student Health History Update