New Student Questionnaire
All the following information is for the school nurse and will remain confidential. Some of these questions are not covered by the standard registration paperwork but will help me better care for your child.
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Email *
Child's first and last name (legal name) *
What is the best phone number to reach you? *
Does your child (check all that apply) *
Required
Has your child  (check all that apply) *
Required
Please elaborate if one of the above apply *
Are you or has anyone ever been concerned about your child's development? *
If yes or maybe to the above question please explain here *
Does your child take a daily medication? Or need medication regularly? *
If yes to medications, please elaborate: *
How does your child respond to pain? *
Has your child ever been diagnosed with the following (check all that apply) *
Required
Please elaborate on any of the above checked ailments. Please include how you help to alleviate these at home. *
Is there anything else you would like the nurse to know about your child's health? *
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