2023-2024 Annual Student Health History Form

Annual Student Health History Form

2023-2024 School Year
Student's Name*

First NameLast Name
Student's Preferred Name*
{studentsPreferred}'s Date of Birth*

MonthDayYear
Date
{studentsPreferred}'s Grade for 2023-2024*
Name of Parent/Guardian filling out this form*

First NameLast Name
Parent/Guardian Email*

Confirmation Emailexample@example.com
Parent/Guardian Phone Number*

Area CodePhone Number
{studentsPreferred}'s Primary Health Care Provider*
Primary Health Care Provider Phone Number*

Area CodePhone Number
{studentsPreferred}'s Dentist*
Dentist Phone Number*

Area CodePhone Number
Will your child need any prescription or over the counter medications given at school?*

YesNo
List medication(s) given at school and reason prescribed:*
Please note: State law and school policy require written permission from a Healthcare Provider and parent/guardian each year or whenever there are changes before any medication can be given at school. Medication Order forms are available at the school office or online at https://mahec.net/patient-information/school-nurses/health-forms
I will provide a Medication Record or Action Plan Form completed and signed by the physician before August 1.
Does your child have any health conditions?*

YesNo
Does your child's health condition require a health plan for school?*

YesNo
Does your child have any of the following diseases or disorders? (check all that apply)
Endocrine Disorders

DiabetesHormonalThyroidOther
Does your child require insulin?*

YesNo
Lungs/Respiratory Disorders

AsthmaTracheostomyCystic FibrosisOther
Has your child used an inhaler or nebulizer in the last 2 years?*

YesNo
Life-Threatening Allergy to:

BeesFoodOther
List food(s) that your child is allergic to:*
Does your child need Epinephrine (EpiPen) at school:*

YesNo
Head/Neurological

ADD/ADHDAutism Spectrum DisorderConcussionCerebral PalsyMigrainesSpina BifidaTourette's SyndromeTraumatic Brain Injury (TBI)SeizuresShuntOther
What date did your child have a concussion?*

MonthDayYear
Date
Cancer
Type and Date Diagnosed
Does your child have an indwelling port?*

YesNo
Blood disorder

AnemiaHemophiliaSickle Cell DiseaseSickle Cell TraitThalassemiaOther
Heart Condition

High Blood PressureIrregular Heart RhythmOther
Bone/Joint

ArthritisLupusUses Crutches, Braces, Walker or WheelchairOther
Kidney/Bladder

CatheterDisposable BriefsUrinary IncontinenceOther
Gastrointestinal

IBS (Irritable Bowel Syndrome)Crohn's DiseaseFeeding TubeRequires Food Modifications (will need a doctor's order)Other
Please list specific food modification requirements (i.e. soft diet, thickened liquids, etc.)*
Ears

Hearing ImpairedCochlear ImplantsWears Hearing AidsOther
Eyes

Prosthetic EyesVision ImpairedWears ContactsWears GlassesOther
Skin

EczemaPsoriasisOther
Behavioral/Emotional

AnxietyBipolar DisorderDepressionEating DisorderOCDODDPTSDOther
Muscular

Muscular DystrophyMultiple SclerosisOther
Genetic/Chromosomal

Down SyndromeFragile XOther
Please list any other conditions/major injuries here:
Please list any medications NOT given at school:
All health information is confidential. School nurses share health information with school staff only on a need to know basis in order to ensure the health and safety of your child, unless otherwise requested by you in writing.
By checking this box, I attest that the health information provided is accurate and up to date.
Parent/Guardian Signature*

Clear
Should be Empty: