SHS Annual Health Questionnaire 2021-2022
The information in this form will be kept confidential and shared only with those on an "as needed" basis for the safety/welfare of your student.
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Email *
Student's Last Name *
Student's First Name and Middle Initial *
Grade of student *
Student's Date of Birth *
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Student's Address *
Parent/Guardian's Name and Phone numbers *
Is the previous listed individual a legal guardian? *
Second Parent/Guardian's Name and Phone Number
Is the previously listed individual a legal guardian?
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Do we have permission to administer Tylenol to this student? *
Do we have permission to administer Ibuprofen to this student?  (We can not administer more than 400mg without a phyisican's order) *
Do we have permission to administer Benadryl to this student? *
Has your child received the COVID-19 Vaccination?
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Is this student covered by health insurance? *
Name of student's physician
Date of last physical exam (annual well child exam is recommended)
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Name of student's Dentist
Date of last dental exam
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Does this student have any allergies? *
If yes, what allergies do they have?
Please list any medications that the student takes regularly.
Has a doctor, nurse or other health professional EVER said that this student has asthma? *
If yes, does your student still have Asthma
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If yes, to the previous question, what medications are used to treat this Asthma?
If your student has any physical disabilities or problems, including speech or hearing problems, please explain and give ay modifications that need to be made at school?
In case of accident or illness, I request the school contact me.  If unable to reach me, or if the emergency is acute, I authorize the school personnel to seek emergency medical care, including transportation to the emergency room.  I authorize the physician in charge to administer whatever emergency treatment is necessary, and I will take responsibility for any expenses incurred. *
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