SAMPLE                                                       

XYZ Charter

719 Fourth Street

Anytown, TX

555/555-1234

 

Student Health Information Form

 

Name: _____________________________________________________________________

 

Birth Date: ___________________ Grade on September 1, 20__: ________ Sex: ¨ Male  ¨ Female

 

Doctor’s Name: ________________________ Doctor’s Office Phone: __________________

 

  1. Does your child have any allergies?

 

To foods?             No______ Yes______ Please list____________________________

 

To drugs?              No______ Yes______ Please list____________________________

 

To bee stings or other insects? No____Yes____ Please list ______________________

 

Explain symptoms, severity of reaction, treatment, and need for EMERGENCY TREATMENT

(Epi-pen, etc.)______________________________________________________________________

 

___________________________________________________________________________

 

       2. Does your child have asthma?   No____ Yes____ Treatment_____________________

           (Please see XYZ Charter School policy for use of inhalers at school.)

 

  1. Does your child take any daily medication at home?  No ____ Yes ____

 

Name, dose, frequency___________________________________________________

 

  1. Does your child need any daily medication at school?  No _____ Yes ______

 

Name, dose, frequency___________________________________________________

(Please see XYZ Charter School policy for medication at school.

 

      5.  Has your child ever had any of the following: (CHECK IF THE ANSWER IS YES)

 

Anorexia, bulimia

 

Hearing difficulty

 

Spinal curvature

 

Bone/nerve/muscle

condition

 

Arthritis

 

Blood problems

 

Kidney problems

 

Cancer

 

ADD/ADHD

 

Heart condition

 

Gastrointestinal

 

Seizures

 

Vision correction

 

Over/underweight

 

Condition

 

Severe injury

 

Surgeries

 

Severe headaches

 

Other

 

Diabetes

 

Dental problems

 

Emotional problems

 

If “yes” to any of the above problems, explain/give dates______________________________ (Please use back of page for additional details.  Attach any medical instructions or treatment plans from your physician.)

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  1. Does your child have any medical or physical restrictions?  No______ Yes______

If yes, please explain.  A doctor’s prescription is needed for restrictions.

 

 

 

 

 

 

 

 

 

Immunizations: A copy of the most recent immunization record must be in the nurse’s office at the start of the school year.  Please check with your doctor or health clinic for all requirements this year.  Some students will need Tetanus boosters.  Varicella (chickenpox) and Hepatitis B (series of 3) need to be completed by age 12.  To omit the need for a chicken pox vaccine, a statement by a parent is required showing proof that their child(ren), born on or after September 9, 1998, did have chicken pox and on what date.  Hepatitis A (series of 2) is required in selected counties for children born on or after September 2, 1992. 

 

In case of emergency, I give XYZ Charter School personnel permission to obtain medical assistance and sign any papers necessary for emergency medical treatment for my child if I cannot be reached.  I realize the school cannot assume responsibility for the payment of medical fees or expenses incurred.

 

 

________________________________________

Parent/Guardian name

 

________________________________________                 ___________________________

Parent/Guardian signature                                                      Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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