2016-2017 Health Information Form
Lakes International Language Academy

Confidential Student Health Information

Dear Parent/Guardian:
Your child's health may affect his or her learning. Therefore, health information is important in planning for your child's needs at school. To ensure the best care for your child, your input and involvement is important. Please continue to update health staff as your child's health needs develop and change. Complete this online form before Monday August 29.

________________________________________________________________________________

Health Concerns
Please check and explain if your child has any of the following:
Student's First Name
Your answer
Student's Last Name
Your answer
Parent/Guardian Name:
Your answer
No Health Concerns
(See below for signature)
Allergies:
( to what foods, medication, environmental?) **A food allergy will require a Special Diet Statement form signed by a medical authority**
Your answer
Epi-Pen Needed:
Asthma or other breathing problems:
Your answer
Inhaler needed:
Lactose Intolerant:
For alternate milk options, please email prundhaug@lakesinternational.org (MD order required)
Your answer
Diabetes:
Diabetes Managed by:
Concussion/Brain Injury
(Please note type of injury and date)
Your answer
Received Special Education/IEP/504 Services during the last school year
Your answer
Any other health concerns or significant history of problems:
(Seizure,heart, ADHD/ADD, etc.)
Your answer
Vision:
Date of Last Exam
MM
/
DD
/
YYYY
Hearing
MM
/
DD
/
YYYY
Hearing/Vision Details
Your answer
Medications
Throughout the year please notify the health office of any medication and/or dosage change.

All Medications that are considered a CONTROLLED SUBSTANCE will need to be brought to the Health Office by a PARENT/GUARDIAN

First, list ALL medications that your child takes at home:
Your answer
Now, list ALL medications that your child needs DURING THE SCHOOL DAY. A completed Authorization for Administration of the Medication at School is required each school year for prescription AND over-the-counter medications.
Your answer
Permission
Please enter your name below to attest to the above information and give permission for its release for confidential use in meeting my child's health and educational needs in school. (If you do not give permission for release, contact school administration)
MM
/
DD
/
YYYY
Please enter your name below to attest to the above information and give permission for its release for confidential use in meeting my child's health and educational needs in school. (If you do not give permission for release, contact school administration)
Parent/Guardian name:
Your answer
Email address
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of Lakes International Language Academy. Report Abuse - Terms of Service - Additional Terms