HRMS Health Form

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HRMS Health Form

Please provide the nurses with pertinent health information which will help us provide the best possible care for your student.

Email *

Untitled Title

What is your student's name? *

What is your student's date of birth? *

Does your child have any of the following health conditions?

Anxiety/Depression

ADD/ADHD

Allergy: food

if above box is checked, please check this box if they are prescribed an EpiPen

Allergy: medication

Allergy: other

Asthma

Bathroom/toileting problem

Blood disorder

History of concussions

Diabetes

Eating disorder

Hearing problems

Heart condition

Kidney disorder

Migraine headaches

Orthopedics/joint issue

Seizures

Sleep disturbance

Vision problems

If you checked any of the boxes above, or if your child has a medical condition not listed, please explain (including specific food, medication, or other serious allergies and reactions).

List ANY medication your child is taking.

Past history of injuries, illnesses, hospitalizations, or surgeries?

Please list any other conditions not listed above.

Do you give permission for Tylenol to be administered to your child? *

Yes

Do you give permission for Motrin to be administered to your child? *

Yes

Do you give permission for Tums to be administered to your child? *

Yes

Do you require a phone call to be placed home prior to administering over-the-counter medications (Tylenol, Motrin, Tums)? *

Yes

Please list the name of your child's health insurance.

Is your child's health insurance public or private?

Public

Private

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