Steel Valley School District: Health Inventory

Annual Health Inventory
Student Name:*

First NameLast Name
Student Birthdate*

MonthDayYear
Date
Student Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Primary Contact:*
Please enter a valid phone number.
Student Grade Level*
Date of Last Physical Examination*

MonthDayYear
Date
Doctor/Practice Name:*
Please indicate any of the following during the past year:*

HospitalizationSurgerySerious IllnessSpecial Tests or Studies (x-ray, EEG, blood test, EKG, et al)Special Examinations (vision, hearing, neurological, psychological, et al)Accidents/InjuriesEmotional/Behavioral problemsContagious DiseaseRecent ImmunizationAllergies (hay fever, stinging insects, asthma)MedicationsFrequent ear infectionsConvulsionsHearing AidGlassesN/A
If you have checked any of the above, please explain/provide pertinent details below:
i.e. reason for hospitalization, type of allergy, type of special exam, etc.
PLEASE NOTE:

If your student has had a new/significant medical change (as listed above) -

you must contact Nurse Amber

at 412.464.3600 x2530.
I understand that any new/significant medical change should be communicated directly to the Nurse by phone at 412.464.3600 x2530*

yesno
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: