WVA Student Health Form
Please complete ONE PER STUDENT
Email *
SECTION A: Demographics
Student's Full Legal Name *
Student's Date of Birth *
MM
/
DD
/
YYYY
Student's Gender *
Parent/Legal Guardian First and Last Name *
Parent/Legal Guardian Phone Number *
SECTION B: Life-Threatening Health Conditions
Does the student suffer from:
Severe Allergies/Anaphylaxis *
If YES, please describe
Does the student have Epinephrine prescribed?
Clear selection
Has the student ever been given an Epinephrine injection? If so, when?
Asthma *
If YES, please describe asthma triggers
Does the student have an Inhaler?
Clear selection
Is the student prescribed regular nebulizer treatments?
Clear selection
Diabetes *
If YES, is there medication prescribed, glucose monitoring, or insulin administered?
Seizures *
If YES, please describe and if medication is needed during the school day.
SECTION C: Current Physical Health Conditions
Please mark if the student has any of the following:
If any of the above were marked, please provide details below.
SECTION D: Emotional/Mental Health Conditions
ADD/ADHD *
Required
Anxiety *
Required
Depression *
Required
Eating Disorder *
Required
Any other emotional/mental health conditions, please describe.
SECTION E: Other Health Needs
If your child has a health condition that requires any health procedures or need any special equipment during the school day, please describe it below:
SECTION F: Medications
Please list all medications and dosages you child receives on a daily basis and indicate which ones will need to be taken at school:
Please Note: A Parent/Guardian is responsible for providing the school with any medication, special food, equipment, that the student may require during the day.
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