Student Health Information

Student Health Information
We would like your child to gain the most from his/her school experience. In order for us to assist in accomplishing this, it is necessary to have a current health history. Please complete the form and submit it as soon as possible.

All information contained in this questionnaire is strictly confidential and will become part of your child's medical record.
Child's Name (Last, First)
Gender
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address
Parent 1 - Name
Parent 1 - Email
example@example.com
Parent 1 - Phone Number
Parent 2 - Name
Parent 2 - Email
example@example.com
Parent 2 - Phone Number
House Doctor
Secondary contact person in case parents cannot be reached
Secondary contact phone number
Relationship to family
Date of last physical exam

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Medical Information and Health History
Childhood illness
Allergies
Does your child have any known allergies to medications? Please type of medicine, reactions/symptoms and treatments.
Does your child have any known allergies to any of the following: bee stings, pollen, dust or animals? Please specify type of allergen and list reactions/symptoms and treatments.
Does your child have any food allergies or diet restrictions? Please list type(s) of food, reactions/symptoms and treatment.
Does your child have any other allergies? Please list reactions/symptoms and treatment.
Does your child have a history of severe allergy or anaphylactic reaction? Has he or she been prescribed an Epipen? Please list dosage of Epipen (if applicable).
Please provide two (2) Epipens for your child here at the school; one to keep in the ISC Nurse's Office and one to keep in their homeroom.
Has your child ever required treatment for any of the following conditions?
Asthma - List date of last attack, if there is an inhaler prescribed and what the dosage is (including number of times per day).
Diabetes - List whether Type 1 or 2 and what treatments are to be provided.
Seizures / Epilepsy - List date of last seizure and any treatment.
Heart Condition - Please specify type of condition, symptoms and treatment.
Bleeding or Endocrine disorders - Please specify type of condition, symptoms and treatment.
Migraine/frequent headaches - List symptoms and treatment.
Hearing problems/ Frequent ear infections - Please describe difficulties, symptoms and treatment.
Vision problems - Indicate whether the child wears glasses/contact lenses, is colour blind or has other vision issues.
Menstrual problems - Symptoms and treatment.
Has your child previously had an injury, serious surgery, long hospitalization or other health condition, which could affect school participation? If yes, please explain and indicate whether treatment is still required?
Any other health conditions (i.e. joint or bone problems: e.g. fracture, dislocation; kidney disorder, scoliosis, fainting etc.)? If yes, please explain and indicate whether treatment is still required?
Any motor development difficulties? Has any physiotherapy treatment been required?
Medications
Does your child take medication?
Please list medication, purpose and dosage.
If your child is on PRESCRIPTION medication: please fill out the release form available at the nurse's office.

If necessary, would you like the school nurse to administer any of the following medications

Rows	Yes	No
Paracetamol/Aramol/Tylenol
Pepto Bismol
Advil/Ibuprofen

Is there anything more about this childs health that you think is important for me to know?
ParentsGuardians Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Student Health Information

Medical Information and Health History

Allergies

Has your child ever required treatment for any of the following conditions?

Medications