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
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Email *
Name of parent completing form *
Student Last Name *
Student First Name *
Date of Birth *
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Grade *
HAS THE STUDENT HAD ANY HOSPITALIZATIONS IN THE LAST YEAR? IF YES, PLEASE EXPLAIN. IF NONE, PLEASE ENTER "NONE". *
DOES THE STUDENT WEAR GLASSES? *
PLEASE LIST ALL MEDICATIONS THE STUDENT CURRENTLY TAKES, INCLUDING NON-PRESCRIPTION. IF NONE, PLEASE ENTER "NONE". *
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.
IS YOUR DAUGHTER CURRENTLY UNDER THE CARE OF A MENTAL HEALTH PROVIDER? *
HAS YOUR DAUGHTER PREVIOUSLY BEEN UNDER THE CARE OF A MENTAL HEALTH PROVIDER? *
Emergency Contact Name (in addition to Parent/guardian) *
Emergency Contact Relationship to Student *
Emergency Contact Cell Phone Number *
Is there anything else that you would like to share with the nurse?
A copy of your responses will be emailed to the address you provided.
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