Student Health History Form
Student health information within the school is limited to the information necessary to serve the students' educational and health interest. This form must be completed for each child.
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Student's Name *
Date *
MM
/
DD
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YYYY
Grade *
Please let us know your child's health needs by completing this form. *
Allergies:
Is there an Epi-Pen prescribed? (If your child has been prescribed an Epi-Pen, parents must provide an Epi-Pen).
Clear selection
Asthma:
Clear selection
Is there an inhaler used?
Clear selection
How often is the inhaler used?
What other medications are taken for asthma?
Diabetes:
Hearing Problems:  (Please describe)
Vision Problems:
Has your child been diagnosed with ADD or ADHD?
Clear selection
What medications are taken?
Will medication be needed in school?
Clear selection
What time should the medication be administered?
Time
:
Bone/Joint Problems:
Is a brace worn?
Clear selection
Seizures
Clear selection
Describe your child's seizure activity.
Date of last seizure
MM
/
DD
/
YYYY
Medications taken for seizures
Emotional Concerns
Other Concerns
Name of Physician
Physician Phone Number
Does your child see a specialist?
Clear selection
Name of Physician
Physician Phone Number
Please contact the school personnel for medications forms if your child needs medication at school, including inhalers for asthma or Epi-Pen for severe allergic reactions.  Your child may carry an inhaler or Epi-Pen if medically authorized and developmentally appropriate, after informing school personnel.
Health History Informed Consent
Your signature givers permission for the school staff to take precautions and procedures to protect your child in the classroom and to foster academic success. Your signature is an informed consent to share this health history information with school staff on a need to know basis for emergency plans.
Parent/ Guardian Signature *
Date *
MM
/
DD
/
YYYY
Submit
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