Student Health History
Student health information within the school is limited to the information necessary to serve the student educational and health interests.

Student Name _______________________ School ______________________

School Year ________________ Grade _________________

___ My child has no health problems which would affect his/her school day.

___ My child's health needs include the conditions checked.

___ Allergies, please list _____________________________________________________
What happens? ____________________________________________________________
Is EpiPen Prescribed? Yes ____ No ___ (If yes, parent must provide EpiPen)

___ Food Allergies, please list ________________________________________________
What happens? ___________________________________________________________

___Bee Sting Allergy, What happens? _________________________________________
Is EpiPen Prescribed? Yes ____ No ___ (If yes, parent must provide EpiPen)

___ Asthma Is inhaler used? Yes___ No___ If yes, how often

___Diabetes What medications are taken?_____________________________________
Any special procedures during the school day?___________________________________

___Hearing Problem Please describe _______________________________________

___ Vision Problem
Wears glasses? Yes ___ No ___
Wears Contacts? Yes ___ No ___

___ ADD or ADHD Diagnosed? Medications taken are ___________________________
Will medication be needed at school? __________________________________________

___ Bone/Joint problem or fractures? Which bone or joint? _________________________
Is a brace worn? Yes ____ No ____

___ Seizures-What type? _________________________ Date of last seizure ___________
Medication taken __________________________________________________________

___ Episode of loss consciousness-When? ______________________________________
Any special treatment? ______________________________________________________

___ Emotional Concerns-List _________________________________________________

List any other recurrent medical problem or illness you would like the school to be award of __
___________________________________________________________________________

Name of Student's Doctor _______________________________ Phone No. __________________

Does you child see a specialist? Yes ___ No ___ Name ____________________________________
Phone __________________

Please contact school personnel for medication forms if your child needs medicine at school, including inhalers for asthma or EpiPen for sever allergic reactions. Your child may carry an inhaler if medically authorized and age appropriate, after informing school personnel.

Please list 3 other emergency contacts in case of illness or injury at school and parent is unable to be reached:

1. Name _______________________________________________ Phone No. ___________________________

2. Name _______________________________________________ Phone No. ___________________________

3. Name _______________________________________________ Phone No. ____________________________

Health History Informed Consent

Your signature gives permission for 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 _________________________________________________________________

Phone ______________________ Date ________________

Teacher/or Homeroom