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Enrollment Health Questionnaire
Please complete this questionnaire to aid us in meeting the needs of your student.
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* Indicates required question
Email
*
Your email
Student's Last Name
*
Your answer
Student's First Name
*
Your answer
Student's Date of Birth
*
MM
/
DD
/
YYYY
Has your student ever been diagnosed with any of the conditions listed below?
Allergies to
*
NO Allergies
Food including Nuts
Insect Bites
Seasonal hay Fever
Other:
Attention Disorder
*
NO Attention Disorder
Attention Deficit (ADD)
Attention Deficit Hyperactivity (ADHD)
Autism or Asperger's
*
Neither
Autism
Asperger's
Blood Disorder
*
NO Blood Disorder
Leukemia
Sickle Cell Anemia
Other:
Diabetes: Type I / II
*
NO Diabetes
Insulin
Oral Medication
Heart Conditions
*
Yes
No
Required
If you answered Yes to Heart Conditions, please explain
Your answer
Mental Health Disorder
*
NO Mental Health Disorder
Bipolar
Depression
Schizophrenia
Other:
Neurological Disorder
*
NO Neurological Disorder
Cerebral Palsy
Fainting
Head Injury
Hydrocephalus
Seizures - Epilepsy
Ventricular Shunt
Other:
Respiratory Disorder
*
NO Respiratory Disorder
Asthma
Cystic Fibrosis
Other:
Required
Other Conditions not listed above, please list here
Your answer
Does your student take any medication, for any reason, AT HOME or AT SCHOOL?
*
Yes
No
If your answered Yes to your student taking medications AT HOME or AT SCHOOL, please list here
Your answer
Does your student currently have a 504 or an IEP
*
Neither
504
IEP
Do you need to speak with the RN regarding your student's health conditions
*
Yes
No
My student DOES NOT Have any health conditions
NO Health Conditions
Clear selection
Electronic Signature of Parental Adult
*
Your answer
Relationship to student
*
Your answer
Email
*
Your answer
Phone number
*
Your answer
How do you prefer to be contacted
*
Email
Phone
Date
*
MM
/
DD
/
YYYY
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