Student Health Information Form

Student Health Information Form
Student Name

First NameLast Name
Please check any check any diseases/conditions this child had or has:

Other
Tell us more about your child's asthma (including age of diagnosis):
Will your child need an inhaler at school?
Tell us more about your child's allergy - How severe is it? What happens when your child comes into contact with the allergen? For food allergies, is it ok if the allergen is present in the room?
Will your child need medication at school for their allergies, such as Epinephrine, Zyrtec, Benadryl or similar?
Tell us more about your child's diabetes (including age of diagnosis):
Will your child need medication at school?
Tell us more about your child's seizures (including age of diagnosis):
Will your child need medication at school?
Tell us more about your child's hearing, speech, or vision issue:
Tell us more about your child's mental health diagnosis (including age of diagnosis):
Will your child need medication at school?
Tell us more about your child's behavioral diagnosis (including age of diagnosis):
Will your child need medication at school?
Tell us more about your child's neurodevelopmental diagnosis (including age of diagnosis):
Will your child need medication at school?
Tell us more about your child's condition (including age of diagnosis):
Will your child need medication at school?
(For NEW students only) We are required to have a birth certificate and current immunization records on file.
Please upload your child's birth certificate and immunization records here.

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For any additional health related questions or concerns, please feel free to contact Angelica Anderson at nurse@gsms.org.
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