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Health Form
Posted On:
Tuesday, September 13, 2016
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Healthy Students Learn Better...Nurses Make It Happen!

To Parent or Guardian:

The purpose of this form is to provide the school nurse with additional information regarding your child’s health needs.  The school nurse may contact you for further information.  The information requested is essential for the school nurse to meet the health needs of your child. 

 

This information will be kept confidential.

 (Return to the School Nurse)

 

 

Name of Student (Last, First, Middle)                                                                              Birth Date              Sex           School

 

 

Address (Street)

 

 

Home Telephone Number:          Cell Phone Number:             Additional Phone Number:         Grade          Teacher/Homeroom

 

 

Name of Parent/Guardian (Last, First Middle)                                                                                                                         Work Phone Number:

 

 

Transportation

     Bus Rider Bus Number:                          Car Rider                                     Special Needs Bus                                               After School

 

Part I – Health Information

       
       

 

 

Place your child receives health care:

Your child's Insurance Information:

Place your child receives dental care:

Physician's Name: __________________

ALL KIDS

Dentist's Name: ____________________

Address: ___________________________

  Medicaid                                                                                                       

Address: ___________________________

Phone:_____________________________

No Insurance          

Phone:_____________________________

Community Health Center               

  Other _________

Community Health Center               

  Health Department                                                                                                         

  Private Insurance

  Health Department                                                                                                         

Hospital Clinic               

 

Hospital Clinic               

  No Regular Place

 

  No Regular Place

  Private Doctor /HMO

 

  Private Dentist /HMO

                        

Preferred Hospital: ___________________________                   

 

 

Part II – Medical History Medical Equipment /Procedures Required at School

□  Catheter         □  Gastric Tube      □  Nebulizer Treatments     □  Oxygen Supplement            □  Tracheostomy

 

□  Vagal Nerve Stimulator (VNS)      □  Ventilator    □  Wheelchair       □  Walker    

 

 □  Other Please explain:  

Medications and Procedures at School require a Prescriber/Parent Authorization Form (one for each medication or procedure) Please see your school nurse.

           Please Complete Back of Form (Signature Required)    


Part III – Medical History

□  YES □  NO

 

KNOWN HEALTH PROBLEMS

If NO, go directly to the bottom of the page and provide parent/guardian signature

If YES, and diagnosed by a physician, answer each question below.

□  YES □  NO

□  YES □  NO

 

 Attention Deficit Disorder (ADD)

 Attention Deficit Hyperactivity Disorder (ADHD)

 Requires medication      □ Atschool         □ At Home

□  YES □  NO

 

 Allergies:

         □  Food    _______________________

         □  Insects   ______________________

         □  Environmental   ________________

         □  Medications ___________________    

Hives/rash                                 Medications

 

Breathing difficulty                      Epi-pen 

 

Other: 

□  YES □  NO

Asthma            □ Uses an inhaler at school   

Uses an inhaler at home

 

□  YES □  NO

Blood/Bleeding Problems:   □Hemophilia,   

□ Requires medication    Please explain:                 

 

□Von Willebrand’s,          □Other      

□  YES □  NO

Frequent Nose Bleeds: Please explain

□  YES □  NO

Cancer/Leukemia: Please explain

 

□  YES □  NO

Cerebral Palsy: Please explain

 

□  YES □  NO

Cystic Fibrosis: Please explain

 

□  YES □  NO

Dental Problems: Please explain:

 

□  YES □  NO

Diabetes □ Type 1 Diabetes          □ Monitors Blood Sugars at school               Requires Insulin at school                                     

                                                                                                                               □ Insulin pump     

                                                                                                                               □ Glucagon order   

               □ Type 2 Diabetes           Managed with diet                                      Oral medication            

                                                                                                     

□  YES □  NO

Emotional/Behavioral/Psychological: Please explain:

□  YES □  NO

Gastrointestinal/Stomach Problems: Please explain:

□  YES □  NO

Genetic / Rare Disorders:  Please explain:

□  YES □  NO

Headaches: Please explain:

□  YES □  NO

Hearing Problems: □ Right Ear         Left Ear         □  Both ears        Hearing loss     Hearing aid    

 □  Tubes         □  Cochlear Implant

□  YES □  NO

Heart Condition:        Activity restrictions:                   □ Medications taken at home:     

Please explain:                        

□  YES □  NO

Hypertension (High Blood Pressure): Please explain:

□  YES □  NO

Juvenile Arthritis/Bone-Joint Problems: Please explain:

□  YES □  NO

Kidney/ Bladder/ Urinary Problems: Please explain:

□  YES □  NO

Scoliosis:         □ No Treatment      Wears Brace            Surgery               Family History 

□  YES □  NO

Seizures/Convulsions:Type of seizure: ______________________________________          

Medications:   Diastat       Klonopin       Versed      Medication taken at home     Other _______________

Please explain:                    

□  YES □  NO

Sickle Cell: □ Anemia     □   Trait

 

□  YES □  NO

Shunt:   □ VP shunt    Please explain:

 

□  YES □  NO

Spina Bifida:

 

□  YES □  NO

Special Diet: Please explain:

□  YES □  NO

Vision Problems:   □ Wears glasses        Wearscontacts                   Other

□  YES □  NO

 Other Medical Conditions:  Please include any medications taken at home only.

 

       

Required Signatures

 

Signature of parent(s) or guardian:_______________________________________ Date:_______________________

 

Signature of school nurse: _____________________________________________  Date:_______________________

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