Yinghua Academy Student Health Form 2018-19
Please fill out one form per child attending Yinghua Academy during the 2018-19 school year. Health information is important in planning for your child’s needs at school and will be shared only with necessary staff members.

Email address *
Student's Last Name *
Your answer
Student's First Name *
Your answer
Student's Date of Birth *
MM
/
DD
/
YYYY
Grade for 2018-19 school year: *
Section 1: FOOD ALLERGIES/DIETARY RESTRICTIONS
Please check all that apply. *
Required
Additional information (optional):
Your answer
Could your child's allergy result in an emergency (anaphylaxis)?
If yes, we require an Allergy Emergency Plan on file, signed by a parent. This can be provided by your child’s primary clinic, or created together in consultation with the school nurse. This is due by the first day of school.
Anaphylaxis History: Has emergency epinephrine ever been administered to your child?
If "Yes", please briefly describe the circumstances and dates.
Your answer
Students with severe allergies have the option to sit at the same spot each day at the end of their lunch table for closer monitoring by staff.
Section 2: ASTHMA
Please check all the apply. *
Required
Section 3: HEALTH CONDITIONS
Please list any other current health conditions that your child has (example: seizures, seasonal allergies, eczema). If your child does not have any health conditions, please skip to section 4.
Your answer
Could any of these conditions result in an emergency? Please explain.
Your answer
If yes, we require an Emergency Plan on file, signed by a parent. This can be provided by your child’s primary clinic, or created together in consultation with the school nurse. This is due by the first day of school.
NEW STUDENTS ONLY: HEALTH HISTORY
NEW Students: Please describe all relevant health history, including past health conditions, surgeries, hospitalizations and dates (not already listed above).
Your answer
Section 4: VISION AND HEARING
Vision *
Vision Difficulties:
Please Describe:
Your answer
Glasses:
When should glasses be worn?
If other, please explain:
Your answer
Hearing *
Hearing Difficulties:
Please Describe:
Your answer
Hearing Aids:
Section 6: MEDICATIONS
Please list all medications your child takes at home or will need at school. We recommend medications be taken at home if at all possible. If needed at school, please download the Medication Authorization Form from the Health Services page on the school website to be signed by both parent and health care provider. This is required each school year for any medication kept at school, including prescription, over-the-counter, and supplements, as well as any emergency medications that students self-carry. *
We also have the following stock topical medications that may be used for your child to treat routine scratches, stings, and dry skin: Vaseline, lotion, hydrocortisone cream, and lidocaine pain-relieving skin protectant spray. If your child has a history of reacting to any of these topical medications, please contact the Health Office.
Required
Please list all medications needed at school or leave blank.
Your answer
Please list all medications taken at home or leave blank.
Your answer
Section 7: SOCIAL/EMOTIONAL HEALTH and SPECIAL EDUCATION SERVICES
Does your child have a diagnosed mental/emotional health condition, including ADHD, depression or anxiety? *
Please Explain:
Your answer
Date Diagnosed:
MM
/
DD
/
YYYY
Section 8: ACCESS TO HEALTH CARE
Does your child have a doctor or clinic where they usually go for health care? *
If yes, Primary Health Provider Name and Phone Number:
Your answer
Hospital Preference:
Your answer
I attest to the information provided and give permission for its release for confidential use in meeting my child’s health and educational needs in school. I acknowledge that it is my responsibility to inform the school of any changes to the health status of this student including health conditions, needs, and/or allergies. *
Parent/Guardian Name:
Your answer
A copy of your responses will be emailed to the address you provided.
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