JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Naaleh Online Health Update 2022-2023
Please complete this annual update about covid vaccination, health conditions, medications, permission for OTC medications in school and screening exemptions
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Name of parent completing form
*
Your answer
Student Last Name
*
Your answer
Student First Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Grade
*
9th
10th
11th
12th
HAS THE STUDENT HAD ANY HOSPITALIZATIONS IN THE LAST YEAR? IF YES, PLEASE EXPLAIN. IF NONE, PLEASE ENTER "NONE".
*
Your answer
DOES THE STUDENT WEAR GLASSES?
*
Yes
No
PLEASE LIST ALL MEDICATIONS THE STUDENT CURRENTLY TAKES, INCLUDING NON-PRESCRIPTION. IF NONE, PLEASE ENTER "NONE".
*
Your answer
EXEMPTION FROM STATEWIDE SCREENINGS/OPT OUT Check all that apply. Please note that your daughter will only be exempt if you make the selection here AND we have a current health record on file.
HEIGHT (9TH, 10TH, 11TH)
WEIGHT (9TH, 10TH, 11TH)
BLOOD PRESSURE (9TH, 10TH, 11TH)
SCOLIOSIS (9TH, 11TH)
VISION (10TH)
HEARING (11TH)
IS YOUR DAUGHTER CURRENTLY UNDER THE CARE OF A MENTAL HEALTH PROVIDER?
*
NO
YES
HAS YOUR DAUGHTER PREVIOUSLY BEEN UNDER THE CARE OF A MENTAL HEALTH PROVIDER?
*
NO
YES
Emergency Contact Name (in addition to Parent/guardian)
*
Your answer
Emergency Contact Relationship to Student
*
Your answer
Emergency Contact Cell Phone Number
*
Your answer
Is there anything else that you would like to share with the nurse?
Your answer
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
Privacy
Terms
This form was created inside of Naaleh High School for Girls.
Report Abuse
Forms
