Yearly Student Health Information Form
ADVERTISEMENT
1SYCAMORE SCHOOLS DISTRICT #427
STUDENT HEALTH INFORMATION
Student Name__________________________________ Grade_____ School __________ Date_____________
Parent Name ___________________________________ Physician’s Name ____________________________
Please provide the health information requested below and sign where indicated. If you have specific issues or
concerns about your child’s health, contact the school nurse.
Allergies: (food, drug, insect, other)
Medications: (list all prescribed or taken on regular basis)
Diagnosis of Asthma?
Yes No
Indicate Severity
Loss of function or one
Child wakes during
of paired organs?
Yes No
night coughing?
Yes No
(eye/ear/kidney/testicle)
Birth defects?
Yes No
Hospitalizations?
Yes No
When? What for?
Developmental delay?
Yes No
Blood disorder?
Surgery? (list all)
Hemophilia, Sickle Cell,
Yes No
When? What for?
Yes No
Other? Explain
Diabetes?
Yes No
Serious injury or
Yes No
illness?
Head injury?
TB skin test positive
*If yes, refer to local health
Yes No
Yes* No
concussion/passed out?
(past/present)?
department
Seizures? What are they
TB disease
Yes No
Yes No
like?
(past/present)?
Heart problem/shortness
Tobacco use (type,
Yes No
Yes No
of breath?
frequency)?
Heart murmur/high
Alcohol/Drug use?
Yes No
Yes No
blood pressure?
Dizziness or chest pain
Family history of
with exercise?
Yes No
sudden death before
Yes No
age 50? (cause?)
Eye/Vision problems?___________ Glasses Contacts
Braces Bridge Plate other:
Last exam by eye doctor _________
Dental
Other concerns? (crossed eye, drooping lids, squinting,
difficulty reading)
Ear/Hearing problems?
Other concerns?
Yes No
Yes No
Bone/Joint problem
Information may be shared with appropriate personnel for health and
Injury/scoliosis?
educational purposes.
Yes No
Parent/Guardian signature
Date
ADDITIONAL HEALTH INFORMATION
ALLERGIES YES _____ NO _____
1. What causes an allergic reaction? ______________________________________________________
2. What are the symptoms of the reaction? _________________________________________________
(if YES – please provide one to school)
3. Use of epipen needed? Yes No
OTHER HEALTH CONCERNS (Include ADD/ADHD, depression, bipolar disorder, orthopedic conditions,etc)
____________________________________________________________________________________
____________________________________________________________________________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical