Commonwealth Of Virginia - The Liberty Common School
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1LIBERTY COMMON SCHOOL
ENTRANCE HEALTH FORM
Health Information Form
The parent or guardian completes this page. This form must be completed prior to the beginning of each school year.
Students Name (Last, First): ______________________________________________________________________________ Entering Grade: _____________________
Name of Parent or Legal Guardian 1:
Phone:
-
-
Work or Cell:
-
-
Name of Parent or Legal Guardian 2:
Phone:
-
-
Work or Cell:
-
-
Condition
Yes
Comments
Condition
Yes
Comments
Allergies- Drugs
Allergies- Animals/Insects
Allergies- Environment/ seasonal
Allergies- Latex
Allergies- Food
ADD/ ADHD
Autism/ Asperger’s
Anxiety
Asthma/ Breathing problems
Behavioral issues
Bipolar
Bladder/ Bowel problem
Bleeding problem
Cystic fibrosis
Cerebral Palsy
Dental problems
Depression
Developmental Delay
Diabetes
Eating Disorder Issue
Headaches (including migraine)
Head injury, concussions
Heart problems
Muscle/ Orthopedic problems
Nutritional/ Growth issues
Seizures/ neurological
Speech problems
Stomach problems
Vision problems:
Hearing problems or Deafness:
Close Range/ Distance
Hearing aid worn
Color Vision
Preferential Seating
Describe any other important health-related information about your child (for example; feeding tube,
hospitalizations,
oxygen support, hearing aid, dental appliance,
Etc.):
List all prescription, over-the-counter, and herbal medication your child takes regularly:
□ Yes
□ No
Check here if you want to discuss confidential information with the school nurse or other school authority
Please provide the following information:
Name
Phone
Pediatrician/primary care provider
Dentist
I voluntarily provide this health information to my child’s school and understand that it is confidential and is only shared with staff on a need to know
basis.
X: ____
Parent/ Guardian Signature
Date
Liberty Common School- 5/2015
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