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RHS Nurse Request
*If you are caught making a false request you will be disciplined from administration*
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* Indicates required question
Date
*
MM
/
DD
/
YYYY
Student Name
*
Your answer
Teacher (current class)
*
Your answer
Date Of Birth
*
Your answer
Reason For Visit
*
Headache
Stomach Ache
Fever
Hit Head
Sore Throat
Not Feeling Well
Coughing
Lost Tooth
Lice/Head Check
Eye Issues
Skin Rash
Nosebleed
Minor Injury(non bleeding)
Minor Injury(Bleeding)
Major Injury
Vomiting
Clothing Issue
Other:
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