Check all conditions your child has or has been treated for in the past. Please explain if condition(s). List any medications that child is taking related to that condition.
Diabetes
Your answer
Seizures
Your answer
Allergies (Food, Animal, Environment) please be specific
Your answer
Lung/ Respiratory Disease (Asthma)
Your answer
Heart/Cardiovascular Conditions
Your answer
Head Injury/Concussion
Your answer
Behavior or Emotional Difficulties
Your answer
Attention Disorders (ADD, ADHD)
Your answer
Neurological Disorders
Your answer
Mental Health Conditions (e.g. Anxiety, Depression)
Your answer
Fainting Spells and Dizziness
Your answer
Kidney/Bladder Conditions
Your answer
Ear/Eyes/Nose/Sinus Problems
Your answer
Muscle or Bone Conditions
Your answer
Abdominal/Stomach/Digestive Problems
Your answer
Migraines or Severe Headaches
Your answer
Food Restrictions/Special Diet
Your answer
Skin Conditions
Your answer
Mobility Problems or Activity Restrictions
Your answer
Learning Problems
Your answer
Vision Concerns
Your answer
Vision Concerns:
Date of last professional eye exam
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Results of the eye exam
Your answer
Hearing Concerns
Your answer
Hearing Devices
Please share any other medical concerns or conditions you may have about your child.
Your answer
Please list any medications (prescription, over the counter, inhalers, epipens etc.) or supplements your child is taking at home and school. **********Please include the medication name, dose, frequency and reason.
Your answer
Would you like to schedule a conference with the licensed school nurse to discuss a particular health concern
Clear selection
The information you provide will only be shared with school staff who required access to this information to meet your child's health and safety needs while at school. Not providing complete and accurate information may result in an incomplete health and safety plan for your child.
Parent/ Guardian Signature *
Your answer
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Time
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Best contact email address to use if we need to contact you with any questions.
Your answer
Best contact phone number to use if we need to contact you with any questions.
Your answer
A copy of your responses will be emailed to the address you provided.