Health Services Intake Form

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Email *

Student's first name: *

Student's middle name: *

Student's last name: *

Student's gender: *

Male

Female

Non-Binary

Student's date of birth: *

YYYY

Student's age: *

Student's place of birth (include city and state): *

Grade: *

Pre-K

Kindergarten

Required

Parent/Guardian 1 - Last name: *

Parent/Guardian 1 - First name: *

Parent/Guardian 1 - Middle name: *

Parent/Guardian 1 - Relationship to child: *

Parent/Guardian 1 - cell phone number: *

Parent/Guardian 2 - Last name:

Parent/Guardian 2 - First name:

Parent/Guardian 2 - Middle name:

Parent/Guardian 2 - Relationship to child:

Parent/Guardian 2 - cell phone number:

Student lives with: *

Mother

Father

Both Parents

Guardian

Other:

Home address - Street/route with number: *

for example: 42 Husky Lane

Home address - Apartment number (optional):

Home address - City/town: *

Home address - State: *

Home address - Zip code: *

Home phone number: *

Parent/Guardian 1 - Employer: *

Parent/Guardian 1 - Employer's phone number: *

Parent/Guardian 1 - Employer's address: *

Parent/Guardian 2 - Employer:

Parent/Guardian 2 - Employer's phone number:

Parent/Guardian 2 - Employer's address:

Please provide the name of someone who can come for the child if neither parent/guardian can be reached at home or work in the event of an emergency:

Emergency contact's relationship to the child:

Emergency contact's phone number (indicate home or cell):

Emergency contact's address:

Family physician/pediatrician's name:

Family physician/pediatrician's phone number:

Family dentist's name:

Family dentist's phone number:

Comments or concerns:

Has your child ever had an ongoing medical condition? *

Yes

If he/she has had an ongoing medical condition, please explain and include dates.

Has your child ever seen a medical specialist? *

Yes

If he/she has seen a medical specialist, please explain and include dates.

Has your child ever had allergies? *

Yes

If yes, which type?

food

environmental

insect

medication

Other:

If there is a food allergy, please specify.

Has your child ever been hospitalized? *

Yes

If he/she has been hospitalized, please explain and include dates.

Has your child ever had an operation? *

Yes

If he/she has had an operation, please explain and include dates.

Has your child ever had an injury requiring an Emergency Room visit? *

Yes

If he/she has had an injury requiring an ER visit, please explain and include dates.

Has your child ever been prescribed an Epipen? *

Yes

If he/she has been prescribed an Epipen, please explain and provide dates.

Has your child ever had a bone/muscle injury? *

Yes

If he/she has had a bone/muscle injury, please explain and provide dates.

Has your child ever passed out, had a concussion, or a serious head injury? *

Yes

If he/she has passed out, had a concussion, or serious head injury, please explain and provide dates.

Has your child ever had a convulsion/seizure? *

Yes

If he/she has had a convulsion/seizure, please explain and provide dates.

Has your child had a vision problem or condition? *

Yes

If yes, does he/she wear (check any that apply):

glasses

contacts

Has your child had a hearing problem or condition? *

Yes

If yes, does he/she have (check any that apply):

hearing aid

cochlear implant

Has your child received the COVID vaccine? *

Yes

Do not wish to answer.

If yes, is the series complete?

Yes

Clear selection

Have any family members under the age of 50 ever had a heart attack? *

Yes

If you have had a family member under 50 have a heart attack, please specify.

Have any family members under the age of 50 ever had other serious health problems? *

Yes

If you have had a family member under 50 have other serious health problems, please specify.

Check all that apply to your child:

ADHD

Asthma/trouble breathing

Autism/Asperger

Dental injuries

Diabetes

Ear infections

GI Conditions (ulcer, reflux, IBS)

Headaches/migraines

Heart Conditions

High Blood Pressure

Mental Health Condition (depression, eating disorder, anxiety, OCD, ODD, etc.)

Scoliosis

Single Kidney

Single Testicle

Skin Condition

Speech Condition

Urinary Condtion

Does your child require any medications that are administered at school? *

Yes

If he/she does require medications administered at school, please list the name, dose, and time(s) for each.

Does your child require any mediations that are administered at home? *

Yes

If he/she does require medications administered at home, please list the name, dose, and time(s) for each.

Does your child require assistive equipment during our outside of school? *

Yes

If he/she does require assistive equipment, check all that apply.

crutches

walker

wheelchair

Other:

Does your child require regular treatments during or outside of school? *

Yes

If he/she does require regular treatments, check all that apply.

insulin/blood glucose monitoring

inhaler/nebulizer/peak flow monitoring

special diet

Other:

Is there any condition that would prevent your child from participating in physical education or sports? *

Yes

Please list any additional concerns:

Name of the parent/guardian completing this form: *

A copy of your responses will be emailed to the address you provided.

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