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.*

ADD/ADHDAsthmaBone/SpineHeartSpeechAllergiesBowel/BladderInfectionsSurgeryAsthmaDiabetesKidneyVisionBlood DisorderEmotionalPhysical DisabilityBody Piercing/TattooHearingSeizuresOther
Comment:
please explain other
2. Does your child have allergies to medicine, food, latex or insect bites?*

Yes (answer below)No
To What?
What Happens?
Treatment(s)?
3. Has your child had any illnesses since school last ended?*

Yes (answer below)No
a. Types of illness with date(s)?
4. Has your child had surgery since school last ended?*

Yes (answer below)No
a. Types of surgery with date(s)?
5. Has your child received any immunizations since school last ended?*

Yes (answer below)No
a. Types of immunization with date(s)?
6. Is your child being treated or evaluated for any health conditions?*

Yes (answer below)No
List condition(s):*
7. Is your child on any medication or treatment?*

Yes (answer below)No
Name medication and or treatment(s):
7a. Does your child need medicine during school hours?*

Yes, if so, please see the school nurse to make arrangementsNo
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?*

Yes *If yes, please contact your school nurse or school counselor.No
12. Have you, your child or anyone in your household tested positive for COVID-19?*

Yes *If yes, please contact your school nurseNo
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?*

Yes (answer below)No
Glasses provided?*

YesNo
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*

Acetaminophen (Tylenol)Ibuprofen (Advil, Motrin)BenadrylTumsAmbesolO.T.C. Topical/LotionsSore Throat Spray
Signature*

Clear
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