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Nurse Visit
Sorry to hear you aren't feeling well! Fill out this form and I'll call you down to see how I can help.
-Mr. McDonald
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* Indicates required question
What is your first and last name?
*
Your answer
What is your ID number?
*
Your answer
Grade
*
6th
7th
8th
Who is your teacher right now?
*
Your answer
Who is your teacher next period?
*
Your answer
What's wrong? If you don't see an option or need to add details, write a quick description in the next section.
*
Stomach ache
I think I have a fever
Headache
I feel like I'm going to throw up
Diarrhea
Short of breath
Sore throat
Congested
My ear hurts
Cut/scrape/bruise
Bumped my head
Other: Fill out the next section with details
Details or reasons not listed above:
Your answer
Rate your pain using the smiley face chart:
*
No pain
0
1
2
3
4
5
6
7
8
9
10
Worst pain possible
When did this start?
*
MM
/
DD
/
YYYY
If it started today, what time did this start?
*
Time
:
AM
PM
All done! Please press submit and I'll call you down as soon as I can.
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