STUDENT HEALTH INVENTORY

Your child’s learning depends on good health. To assist in providing health services at school, please complete the Student Health Inventory form.

If your child is injured or becomes ill at school, the child will be sent to the clinic. If needed, you will be called to pick him/her up.

Contact the school clinic director to schedule medication administration. Forms are available in the Health Services Department and the school-clinic web page.

Name________________________________________________ Birthdate _______

Last First Middle

Teacher__________________________ Grade________

Does the student have:

Allergies? Yes__ No__

To drugs, foods, insects, pollen? Please list_______________________

____________________________________________________________

Has allergy required emergency action in the past? Yes No

Describe____________________________________________________

____________________________________________________________

Bee/Insect sting allergy? Yes__ No__

Describe reaction_____________________________________________

Difficulty breathing? Yes__ No__

Need emergency medication?___________________________________

Asthma? Yes__ No__

Triggered by:________________________________________________

Treatment__________________________________________________

Diabetes? Yes__ No__

Takes Insulin? Yes__ No__ Date Diagnosed________________

Epilepsy / Seizures? Yes__ No__

Describe seizure______________________________________________

Medication__________________________________________________

Is student currently under a doctor’s care? Yes__ No__

Heart condition? Yes No

Describe____________________________________________________

Medication Yes__ No__

Any physical restrictions?_____________________________________

____________________________________________________________

Bone or joint problem? Yes__ No__

Describe__________________________________________________________

Any physical restrictions?___________________________________________

Check off the following regarding health concerns that pertain to the student:

Eyes: glasses__ contacts__

Ears: Tubes__

Hearing aid__

Frequent ear infections Yes No

Hearing difficulty, explain___________________________________________

Other:

Nosebleeds ADD/ADHD Headaches Braces

Daily medication at home? Yes No At school? Yes No

Emergency only? Yes No

Name of medication and reason for taking____________________________________

________________________________________________________________________

List serious illness or injuries______________________________________________

Surgeries (operations)_____________________________________________________

________________________________________________________________________

Condition that prevents PE participation____________________________________

________________________________________________________________________

Special education or services: OT/PT speech/language

Other health information or concerns_______________________________________

________________________________________________________________________

________________________________________ ___________

Signature of legal parent/guardian Date

Contact the school clinic director to schedule medication administration. Forms are available in the Health Services Department and the school-clinic web page.

Last First Middle

Has allergy required emergency action in the past? Yes__ No__

Describe____________________________________________________

Heart condition? Yes__ No__

Describe____________________________________________________

Frequent ear infections Yes__ No__

Nosebleeds __ ADD/ADHD __ Headaches __ Braces__

Daily medication at home? Yes__ No__ At school? Yes__ No__

Emergency only? Yes__ No__

Name of medication and reason for taking____________________________________

List serious illness or injuries______________________________________________

Condition that prevents PE participation____________________________________

Special education or services: OT/PT__ speech/language__

Other health information or concerns_______________________________________

Has allergy required emergency action in the past? Yes No

Heart condition? Yes No

Frequent ear infections Yes No

Nosebleeds ADD/ADHD Headaches Braces

Daily medication at home? Yes No At school? Yes No

Emergency only? Yes No

Special education or services: OT/PT speech/language