NAPS Student Health Form
Please complete a separate form for each child.
Health Form Instructions
Student First Name *
Your answer
Student Last Name *
Your answer
Student Date of Birth *
MM
/
DD
/
YYYY
Student Gender *
Emergency Care: If the school is unable to contact me, or my designated emergency contact, I authorize NAPS to seek appropriate emergency care for my child from qualified medical/emergency personnel.
Medical Provider *
Name
Your answer
Medical Provider Phone Number *
Your answer
Date of Last Physical Exam *
Must be within the last 12 months
MM
/
DD
/
YYYY
Dental Provider *
Name
Your answer
Dental Provider Phone Number
Your answer
Date of Last Dental Exam
MM
/
DD
/
YYYY
I authorize NAPS to administer pectin lozenge when appropriate: *
I authorize NAPS to administer Vaseline/lip balm when appropriate: *
I authorize NAPS to administer lubricant eye drops when appropriate: *
Is you child 100% toilet trained? *
Has your child ever been evaluated for or diagnosed with any of the following? Comments are required below for any “yes” answer. *
Yes
No
Allergies (food, insect, drugs, latex, etc.)
Allergies (seasonal)
Asthma or breathing
Behavioral condition
Diabetes
Eye or Vision condition
Head injury
Heart condition
Life threatening allergic reactions
Limits on physical activity
Seizures
Developmental Delay
Autism
Deaf-Blindness
Emotional Disturbances
Hearing Impairment
Intellectual Disability
Multiple Disabilities
Orthopedic Impairment
Other Health Impairment (e.g.: ADD, ADHD, or an acute health problem
Specific Learning Disability (e.g.: dyslexia, dyscalculia, and/or dysgraphia)
Speech or language impairment
Traumatic brain injury
Visual impairment (including blindness)
Comments for any "Yes" answers above:
Your answer
Previous Surgeries
Your answer
Menstruation (Female Students Only)
Date of Menstruation Onset
MM
/
DD
/
YYYY
Describe any dietary issues, restrictions, or preferences:
Your answer
Can your child take part in classroom holiday party/birthday treats?
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