HEALTH ASSESSMENT
This Form is to be filled out by the Parent/Guardian, not the doctor. It is submitted in addition to the student's annual physical.
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Student Name: *
Date of Birth: *
MM
/
DD
/
YYYY
Gender: *
Medical History (check all that apply): *
Required
Severe Injuries:
Surgeries (Name & Date):
Vision Problems: *
Hearing Problems: *
List any other Significant Health History Concerns:
ALLERGIES
Does your child have any allergies? *
Allergy #1 - What is your child allergic to?
Allergy #1 - Describe the reaction:
Allergy #1 - Describe the treatment:
Allergy #1 - Is there a history of ANAPHYLAXIS?
Clear selection
Allergy #2 - What is your child allergic to?
Allergy #2 - Describe the reaction:
Allergy #2 - Describe the treatment:
Allergy #2 - Is there a history of ANAPHYLAXIS?
Clear selection
Allergy #3 - What is your child allergic to?
Allergy #3 - Describe the reaction:
Allergy #3 - Describe the treatment:
Allergy #3 - Is there a history of ANAPHYLAXIS?
Clear selection
HEALTH INSURANCE
Does your child have health insurance? *
If yes, what is the name of the Insurance Company?
NJ FamilyCare provides free or low cost health insurance for uninsured children and certain low income parents. I authorize Ewing Public Schools to release my name and address to the NJ FamilyCare program so they can contact me about health insurance. *
Does your child have a personal physician? *
Doctor’s Name
Doctor’s Phone Number
Students new to Ewing Public Schools must have a physical examination. Also, students must provide a copy of immunizations. If you are transferring from a school within the State of NJ, you must provide a copy of immunization upon registration. If you are transferring from out of state or country, you must provide an immunization record within 30 days. If you do not have insurance to cover the cost of the required physical, our school physician can perform the physical for you.
MEDICATIONS
Note: You must provide a physician’s written order for medication to be administered at school. Please ask nurse for a Medication Form.
Medication to be Taken AT SCHOOL (if any): Indicate name, dose, frequency and reason
Medication Taken AT HOME (if any): Indicate name, dose, frequency and reason
May we share pertinent health information with school staff? *
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