Student Health History
Please note: This information is confidential. Information is only shared with staff if there is a legitimate safety concern for a student. Please see the school nurse if you have any concerns regarding your child's health
Date *
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YYYY
Student's Name *
Your answer
Student's Birthday *
MM
/
DD
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YYYY
Grade *
Any Known allergies to food or medications? *
If so what are they?
Your answer
Do you require an epi pen in school? *
Have you ever had an allergic reaction? If so, what happened? *
Your answer
Do you have seasonal allergies? *
Do you have asthma? *
If yes, what are your asthma triggers?
Your answer
Any history of other respiratory conditions? (cystic fibrosis, etc.)?
Your answer
Do you take medication for asthma? *
If so, what kind?
Your answer
Should an inhaler be kept at school? IF YES, SEE THE SCHOOL NURSE *
Do you have any of the following?
Do you have a history of AD/HD *
If yes, are you taking medication for this condition?
Did you get a flu shot this year or do you plan to? *
Please describe any health conditions or concerns regarding your child:
Your answer
Name of parent or guardian *
Your answer
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