Student Health Screening Form Page 2
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2Please check all medical conditions that apply:
INFECTIOUS – RECURRENT INFECTIONS
GENERAL
Recent weight loss or gain
Ear
Heat or cold intolerance
Sinus
Difficulty sleeping
Lung
Skin
HEAD, EYES, EARS, NOSE, MOUTH, THROAT
Bone
Headache
Other: _______________________
Dizziness
Loss of hair
GEMOTPIROMARY
Hearing difficulties
Pain with urination
Dry mouth
Increase in frequency/urgency with urination
Vision, glasses, contacts
Blood in urine
RESPIRATORY
FEMALES ONLY
Asthma
Menstrual cycles, started at age: _______
Use inhaler
Regular cycle
Pregnant
CARDOVASCULAR
Irregular heart beat
MALES ONLY
Murmur
Rash or sores on penis
Palpitations
Discharge from penis
Under a doctor’s care
GASTROINTESTINAL
BONES, MUSCLES, JOINTS
Loss of appetite
Joint pain
Heartburn, indigestion
Joint swelling
Nausea
Muscle pain
Vomiting
Numbness or tingling
Pain or cramps in abdomen
Diarrhea
NERVOUS SYSTEM
Constipation
Seizures
Under a doctor’s care
Vomiting blood
On medication
SKIN
Hives or welts
Easy bruising
Signature of Parent/Guardian
Date
Signature of Student if 18 years of age or older
Date
Should your child have a health condition that is not included on the above list or a condition that has
developed throughout the school year, please contact the School Nurse at (617) 855-2124 so we may
update our medical information records.
Page 2 of 2
FORM M2.01
Last update: Aug-14
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Parent category: Medical