Promontory Student Health Form

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If your student has no known health problems, this form does not need to be completed.

If medications are to be administered during the school day either by said student or by a school employee, the Medication Authorization Form must be completed as per Utah law (53A-11-601) by the attending physician.

The Medication Authorization Form is available on our website or in the office.

Student Name *

Name of Parent or Guardian filling out form *

Date *

YYYY

Please check all that apply to your student:

VISION: Known eye condition (other than corrective lenses)

VISION: Wears glasses

VISION: Wears contacts

HEARING: Known hearing problem

HEARING: Uses hearing aid

HEARING: Has tubes in ears

ALLERGIES: Food (specify below)

ALLERGIES: Environmental (specify below)

ALLERGIES: Medicine (specify below)

Asthma

Diabetes

Epilepsy

Fainting Spells

Heart Condition (specify below)

MIgraines

ADHD/ADD

If more specification is needed for any health conditions or health problems, please clarify here:

List other conditions or health problems:

Does your student have any condition which may result in a classroom emergency?

Yes

Clear selection

Does your student have a physical condition which limits participation in classroom activity?

Yes

Clear selection

Does your student have a physical condition which limits participation in physical education classes?

Yes

Clear selection

Does your student require assistance such as:

Wheelchair

Adult Assistance

Special Equipment

Clear selection

If answered yes to any of the above, or needs special equipment, please explain.

Submit

Clear form

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