Student Health Information - School Form - 2015
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DO NOT WRITE IN THE SPACE BELOW – FOR ENROLLMENT OFFICE USE ONLY
STUDENT ID# ________________________ SY/SCHOOL# ___________/______________
STUDENT HEALTH INFORMATION
Information on this form is to be filled out (updated) for each new school year. Please complete both sides of this form and return to your school nurse as soon as possible.
Name: _____________________________________________________ Birthdate: ________________ Sex: M / F
Last
First
MI
(circle)
School:
Grade: _________ Date: _____________
SPECIAL HEALTH CARE PLANNING
If anything checked for SPECIAL HEALTH CARE PLANNING, send form to Health Services (MS 31-650 or call 206-252-0750)
☐Diabetes – Date of diagnosis: _________________ My student has:
☐ insulin pump ☐ insulin pen ☐ injected insulin
☐Seizure Disorder – My student needs emergency medication for Seizures. Name of medication: ____________________________
☐Special Health Care Planning - My child has special health care needs such as – wheelchair, tube feedings, breathing tube, catheter,
intravenous tubes or other. Please describe your child’s condition(s): _____________________________________________________
____________________________________________________________________________________________________________
☐My child has NONE of the health concerns/conditions listed above.
LIFE THREATENING CONDITIONS
If anything checked for LIFE THREATENING, send form to your child’s school
Asthma *Severe - (If this box is checked, please answer the following questions):
Yes ☐ No ☐ Does child use rescue inhaler routinely for asthma symptoms?
Yes ☐ No ☐ Has your child been hospitalized for asthma in the past year?
Yes ☐ No ☐ Has your child used steroids (prednisone) for asthma symptoms in the past year?
(If mild or moderate asthma, see box below ‘Health History -Non-Life Threatening’
Allergy/Anaphylaxis - *Severe, with Epi Pen/ Auvi-Q prescription (for example: food, insect stings)
Allergen(s):
_________________
Other: _____________________________________________________________________________________________________
☐My child has NONE of the health concerns/conditions listed above.
ALERT TO PARENTS/GUARDIANS: The school must know of LIFE THREATENING conditions (for example severe allergy with anaphylaxis,
diabetes, asthma) prior to the start of school, as these may require an Individualized Health Plan (per RCW 28A.210.320). Contact your School
Nurse or Health Services to begin the process for a student health care plan and/or medications at school.
HEALTH CONDITIONS
Check any of these conditions which your child has or has had:
☐ ADD/ADHD
☐ Blood Disorder
☐ Depression/Anxiety
☐ Heart Problems
☐ Serious Injury
☐ Allergies mild or moderate (circle one)
☐ Bowel/Bladder
☐ Dental
☐ Orthopedic/Bone
☐ Vision Concerns
☐ Asthma mild or moderate (circle one)
☐ Cancer
☐ Hearing
☐ Social/Emotional/Behavioral
☐ Other
If you have checked any of the above medical conditions/concerns, please explain: ________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Has the student ever visited an emergency room or hospital for the medical issue? YES / NO (circle) If yes, date: ________________
___________________________________________________________________________________________________________
☐My child has NONE of the health concerns/conditions listed above.
PLEASE SEE OTHER SIDE
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