Schhol Health Information Form
ADVERTISEMENT
1
2Pulaski County Schools
Health Information Form
Teacher: ________________Sex: M F
School Year: 2015-2016 Grade: _____ School:
Dear Parent or Guardian:
In order to provide the best educational experience, school personnel must understand your child's health needs. Please complete
this form and return it to the school nurse as soon as possible. All medical information is kept confidential. It is only shared with
Pulaski County School Staff who are responsible for your child's care at school. Your child will not be allowed to participate in
field trips, sports or other extracurricular activities until the school nurse has this signed and completed form on file in the
school clinic.
Student’s Last Name: ___________________ First: _________________Middle Initial: ____ Birth date: ________________
Parent/Guardian_______________________________ Phone: Home: __________Work: ____________ Cell #: _______________
Emergency Contact(s) ________________________________Phone: __________________________________________________
Doctor Name: ______________________________________________________________________________________________
*Please list any allergies to: Foods: ____________________________________________________________________________
Bees/Insects: _____________________________Latex: ____________________________________
Are any of these allergies severe enough to require an Epi-Pen? Yes______No______ (If an Epi-Pen is required, we must have a
written and signed Medication Authorization Form from physician and signed by parent.)
Chronic, Recurring and Special Health Conditions (Please check any of the following that apply)
**Asthma
Hearing Problems/deafness
Attention Deficit/Hyperactivity Disorder
Hypoglycemia (low blood sugar)
(ADD/ADHD)
Anemia/Bleeding Problems
Lead Poisoning
Autism
Kidney Disease/transplant
Behavioral Problems
Mental Health Concerns
Bladder/ Problems and/or wetting accidents
Muscle Problems
Bone or Joint Disorders
**Seizures
Bowel problems and/or accidents
Scoliosis
Cancer
Sickle Cell Disease
Cerebral Palsy
Skin Problems/Disease
Cardiac/Heart Problems/Hypertension
Speech Problems
Cystic Fibrosis
Spina Bifida/Spinal injury
Dental Problems/Cavities
Stomach/Intestinal Problem
Depression
Sleep apnea
Developmental Delays/Problems
Seasonal Allergies
*Diabetes
Thyroid Disease
Dizziness/Fainting Spells
Weight Problems
Eating Disorders/problems
Vision Problems/blindness
Emotional Problems
Medication Allergies:
Frequent headaches/Migraines
Frequent Nosebleeds
Other Health Problems (please list)
Head injury/concussions
* Please talk with school nurse about completing a Healthcare plan and medication authorization form.
Please discuss any health problems you have checked (some health problems may require Medication Administration at school
and/or a written health care plan. The school nurse will provide you with the needed Medication Authorization Forms and/or care
plans) ____________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
___________________________________________________________________________
Complete and sign Page 2
1
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical