Sauk Prairie School District-Student Health History for Returning Students
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Please review your child's health information in Family Access then complete the following sections as they apply to your child. If you have questions about your child's health while they are attending school please contact a school nurse.

Child's Name (First and Last) *
Your answer
Child's School *
This refers to the school the child attends when the form is being completed. If summer, please choose the upcoming school.
Child's Grade *
This refers to the grade the child is in at the time the form is being completed. If summer, please choose the upcoming grade.
Name of the person completing the form *
Your answer
Relationship of the person completing the form to the child named above. *
Your answer
Phone number you can be reached at if a school nurse needs to contact you.
Your answer
Today's date *
Your answer
Does your child have health concerns at this time and/or take medication? *
1. After reviewing your child's health information in Family Access, please describe any changes including if your child had any recent illness, injury or surgery?
Please describe illness, injury or surgery in detail or type the word, "no".
Your answer
2. If your child requires emergency medication such as glucagon, epipen, or inhaler are they able to self-administer this medication?
A Medication and Procedure Consent Form is required for school personnel to administer emergency medication or for a student to self-administer emergency medication. For the safety of your child, we need a back up of all emergency medication in the school office.
2a. If you answered yes, please indicate the emergency medication
3. Is your child taking any medications regularly at home?
3a. If your child regularly takes medication at home, please provide: 1) the medication name; 2) dose; and 3) the time they take the medication. This is not a required field but will give the school nurse important information about your child's health needs at school.
Your answer
4. Will your child be taking any medication while at school?
A Medication and Procedure consent Form is required for medication to be administered to a student by school personnel - including over the counter (OTC) medicine.
4a. If your child will be taking medication while at school, please list: 1) the medication name; 2) dose; and 3) the time they take the medication.
Your answer
5. Does your child have any other special health needs/concerns/limitations that may limit their activity at school. Some examples: mobility (wheelchair, walker, crutches, prosthesis); Gaining information (hearing, eyesight, stamina); Allergies
5a. If yes, and not covered in Question #1, please explain.
Your answer
6. Is there a health concern you would like to discuss with a school nurse at this time?
If you choose yes, a school nurse will call you at the number you provide at the top of this form.
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