Health Concerns forms?

The format changed when I pasted this but it may be a starting point for you...good luck.

Student Health Information

Student's Name: Birth Date: Sex: Male/Female

Grade: Teacher or ID#:

Mother's Name:

Father's Name:

Address:

Address:

Home/Cell #:

Home/Cell #:

Work #:

Ext.:

Work #:

Ext.:

Dr.Dr.'s office #:

Alternate People to Notify if Parents Unavailable:

Name:

Relationship:

Phone #:

Name:

Relationship:

Phone #:

Health History (Please complete and notify Nurse if medicine is needed at school)

1. FOOD ALLERGY â–¡ YES â–¡ NO

LIFE THREATENING â–¡ YES â–¡ NOFood(s): Describe Reaction:

Emergency medication(s) needed at school (provided by parent):

2. INSECT ALLERGY â–¡ YES â–¡ NO

LIFE THREATENING â–¡ YES â–¡ NO

Insect Type: Describe Reaction:

Emergency medication(s) needed at school (provided by parent):

3. LATEX ALLERGY â–¡ YES â–¡ NO

LIFE THREATENING â–¡ YES â–¡ NO

Describe reaction:

Emergency medication(s) needed at school (provided by parent):

4. ASTHMA â–¡ YES â–¡ NO

Does your child use an Inhaler?List medication(s)/Inhaler(s):

5. BLOOD DISEASE

Anemia, Hemophilia, etc.

Type:

Medication(s):

6. DIABETES

â–¡ Type 1 â–¡ Type 2

Medication(s):

7. HEART PROBLEMS

Describe:

M.D. Restrictions:

8. ORTHOPEDIC PROBLEM(S)

Type: Surgery:

M.D. Restriction(s)

9. SCOLIOSIS

Treatment:

10. SEIZURE DISORDER

Epilepsy, etc.

Type and Description of symptoms during a Seizure:

Medication:

11. URINARY/KIDNEY DISORDER

Nephritis, etc.

12. VISION PROBLEM and/or

HEARING PROBLEMâ–¡ Glasses â–¡ Contacts â–¡ Hearing Aid(s)

13. A.D.D. (Attention Deficit Disorder) â–¡ or A.D.H.D. (Attention Deficit Hyperactivity Disorder) â–¡ Please Check OneMedication taken:

14. Other Health Problems, Surgeries, Conditions, Medications not listed above

The school cannot assume any financial obligation, but wishes to provide the best service possible in an emergency. By signing this form, you are giving us authority to obtain medical aid as we deem necessary in the event we are unable to locate the child's parent or guardian.

 Parent/Guardian:Date:

The information listed above will be shared with your child's teacher(s) unless otherwise noted by parent/guardian.

OPTIONAL: (E-MAIL ADDRESS FOR NON-EMERGENCY CONTACT)____________