School Health Information Form

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STAFFORD COUNTY PUBLIC SCHOOLS HEALTH SERVICES
SCHOOL HEALTH INFORMATION FORM
Name: _________________________________________________
Birth date: Mo. ____ Day ____ Yr. _____
Last
First
Middle Name
Sex:
Male____ Female ____
Parent or Guardian ______________________________________
Work Phone: __________________________
Last
First
Home Phone: __________________________
Home Address: ____________________________________________ ______ Zip:
_________________________
Person to call in case of an emergency if parent/guardian is not available:
Name: ________________________________________________
Phone:
_________________________
Please provide information relative to the following health concerns of your child and return to office.
____yes ____no
Allergies: type _________
____yes ____no
Heart Disease
____yes ____no
Asthma
____yes ____no
Thyroid Disease
____yes ____no
Cancer : type__________
____yes ____no
Mental Health
____yes ____no
Cerebral Palsy
____yes ____no
Stomach/Intestine
____yes ____no
Ear/Nose/Throat
____yes ____no
Elimination
(bowel or urination)
____yes____ no
Diabetes: type_________
____yes ____no
Eye/Vision
____yes____ no
Seizure Disorder
____yes ____no
ADHD
____yes ____no
Spinal Disorder/Injury
____yes____ no
Hearing
____yes ____no
Other
If yes to any of the above, describe condition and equipment necessary, also list and describe any condition not
listed above.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
_________________________________________________________________________________________________
Surgical History
Describe any hospitalizations/surgeries/fractures:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
_________________________________________________________________________________________________
Medications
LIST ALL PRESCRIPTION AND NON-PRESCRIPTION MEDICATIONS TAKEN AT HOME AND SCHOOL.
A separate permission form is required in order for medications to be given at school.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
I consent to the release of this health information concerning my student ,_______________________ ,
to any Stafford County Public School staff who need to know this information for health and safety reasons when
they are working with my student at school.
Parent/Guardian Signature _______________________________________Date __________________
Revised 1/14
Chapter 2-F3

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