Supplemental School Health Report Form
ADVERTISEMENT
1SUPPLEMENTAL SCHOOL HEALTH REPORT
Student’s Name: ________________________________________
Age: ______
Grade: _______
Date of last dental exam: __________________
NO
New glasses/lenses?
YES
Date of last vision exam: ___________________
Please Circle YES or NO
YES
NO
Did your child have an illness or accident during the summer?
If yes, please explain: __________________________________________________________________
YES
NO
Did your child have any immunizations during the summer?
If yes, please list date and what was given: _________________________________________________
YES
NO
Is your child allergic to medication, food, bee stings or environmental allergens?
If yes, list ALL allergens and reaction for each: ______________________________________________
YES
NO
Does your child take medication(s) on a regular basis?
If yes, list name(s) and times taken: _______________________________________________________
____________________________________________________________________________________
YES
NO
Does your child have a medical diagnosis of a chronic health condition such as diabetes, asthma, heart
problems, seizures, etc.?
If yes, list medical condition: ____________________________________________________________
Additional information: ______________________________________________________________________________
_____________________________________
___________________
Parent/Guardian Signature
Date
****************************************************************************************
MEDICATION REQUEST
It is the policy of the Waukee Community School District that whenever a student should have a prescription medication or over-the-
counter medication administered by school staff, a parent or legal guardian must provide written authorization and instruction. All
over-the-counter medication MUST be in the original container. Prescription medication MUST be in a properly labeled container
issued by a registered pharmacist with the following information: Name of medication, Dosage, Time medication is to be given at
school, Name of student, AND Prescribing physician.
____________________________ is to be given the following medication at school:
(name of student)
Name of Medication
Dosage
Time
Prescribed by
_________________
______
____
___________
_________________
______
____
___________
How long is this medication to be given?
Date from ______________________ to _________________________
Are there any special instructions? _____________________________________________________________________
_____________________________________
___________________
Parent/Guardian Signature
Date
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical