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Sign Up to See the Nurse Form
Please fill out this google form to sign up to see the school nurse.
* Indicates required question
Email
*
Record my email address with my response
What grade are you in?
*
6th Grade
7th Grade
8th Grade
Describe the reason you need to see the nurse: (e.g., headache, stomachache, injury, medication, etc.).
*
Your answer
How would you rate the severity of your issue?
*
Mild: I feel a little uncomfortable, but I can still do most of my usual activities. I don’t think it’s very serious.
Moderate: I’m feeling quite uncomfortable and it’s hard for me to focus on my schoolwork or activities. I might need some help soon.
Severe/ Unable to stay in class: Stop filling out this form and have teacher call the nurse's office for you
How long have you been experiencing these symptoms?
*
Less than an hour
A few hours
All day
More than a day
Is there any other information you would like to provide to the nurse?
Your answer
Submit
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