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This Student Health Form SAMPLE is provided for viewing and information pruposes only. |
NURSING SERVICES
1002 Hastings St.
Delta, Co. 81416
970-874-7607 Fax 970-874-9505
STUDENT NAME: ________________________________ Birthdate: _______________ Grade: _________ SCHOOL YEAR :_______________ School: ___________________________________ |
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HEALTH CONCERNS |
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NO |
Medication AT school (name & dosage) |
Comments |
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Asthma |
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Severe Allergies (Specify) o Food _______________ o Latex o Insects _____________ |
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Diabetes |
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Seizures |
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Head Injury |
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Heart/Blood |
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Muscles/Bones/Joints/Skin |
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Bladder/Kidney |
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Stomach/Intestines/Bowels |
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Immune Problems |
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Hearing Concerns |
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Vision Concerns |
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Glasses/Contacts o Yes o No |
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Growth/Nutritional Concerns |
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Developmental Concerns |
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oEmotional oBehavioral oBullying Concerns |
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ADD/ADHD |
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Other Health Concerns |
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I acknowledge that I have received and understand the Nursing and Health Services parent letter. o Yes o No
Activity Restrictions: _____________________________________________________________________
Special Equipment required: ______________________________________________________________
Illnesses, Hospitalizations, Accidents/Injuries and dates (use other side if needed): _________________
________________________________________________________________________________________
Healthcare Provider Name: _____________________________________ Phone: ____________________
PERMISSION FOR NEED TO KNOW
I give permission to contact the student’s health care provider(s) listed above if needed, regarding the health concerns listed. By signing I agree to the above terms, which shall be continuously in effect for the school year unless terminated by written notice from myself to the school in which my student is enrolled.
Parent/Guardian Signature___________________________________ Date ___________________
Print Name ______________________________________ Relationship to Student ___________________