Heart Health Update Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please take a few moments to answer the following questions.
Your answers will be used to create an individualized school healthcare plan for your child.
Also, information will be shared on a need to know basis with school personnel for health, safety and educational purposes.

Student's Legal Name (last, first) *

Student Graduation Year *

Student's Date of Birth *

YYYY

Current Medical Diagnosis... *

List current medications your child takes... If your child needs to take medication at school a doctor note will need to be on file. https://drive.google.com/file/d/1zyYdEz8nl9uADS1vcvvyQAYG87GAJMuk/view *

Describe any previous or upcoming heart related surgeries... *

Is your child able to participate in the required PE program? *

Yes- without accommodations

No- a written doctor excuse note is required every school year.

Yes- with accommodations (please list under Other option)

Other:

Does your child need permission to use the school elevator? *

Yes

Maybe

Other:

Does your child need any special health accommodations to be successful in the school setting? *

Yes

Maybe

Other:

List doctor name and number who can verify above noted health information. You will need to contact them for a note out of PE too if needed. *

Name of parent/person completing this form... *

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of East Peoria High School Dist 309.

Does this form look suspicious? Report

Forms