Health & Medical Information
Please provide the following information in regards to the health and wellness of your child.
Email address *
Name of Student
Your answer
Any Allergies? *
Required
Describe any reactions to look for and how to intervene.
Your answer
List of Medications and what they are for.
Your answer
If your child takes medication, do they take the medication at home? Or do they need to take it at school?
Asthma? *
Attention Deficit Disorder? *
Diabetes? *
If yes to diabetes, are they insulin dependent/needs school program set up? Or do they self manage (snacks, diet, testing, coverage)?
Headaches? *
If yes to headaches, which medication works best for them?
Your answer
Seizures? *
If yes to seizures, do they need medication at school, they take it at home, or are they not currently on medication?
Hearing concerns? *
Vision Concerns? *
Physical Restrictions?
Doctor's letter is required for some P.E. Adaptations
Describe health history (operations, serious accidents, and serious illness)
Your answer
Diseases/Conditions
Note: If medication is needed, the parent must complete a medication authorization form before the first dose of medication can be given at school. This health concern information may be shared with school personnel as necessary to benefit the health and safety of this student and others. Please keep school staff informed as to any changes to the information provided so the student's records can be updated as needed. *
Please type your name to acknowledge the information provided is correct and you have read the above statement.
Your answer
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