Student Name

First Name

Last Name

Student Name *

First Name

Last Name

PARENT/GUARDIAN-Please check if your student has any of the following *

NO HEALTH CONCERNS

ADHD/ ADD (Attention Deficit Disorder), please add below if medication are taken

Hearing Impairment

Mental Health Concerns (Depression, OCD, etc.)

Migraine Headaches

Mobility Issues (problems with muscle, bone, balance, etc.)

Seizures

Sickle Cell

Vision Impairment, please add below Glasses/Contacts

others, please list below

Allergies, please list below

Asthma or other Breathing problems

Diabetes type I or II, please specify below

Other Health Questions, *

1. Is physical activity limited in any way ?

Yes

No

Hospitalization/Surgery/Injury past 12 months *

Yes

No

3. Any health problems that could result in an emergency? *

Yes

No

4. Does the student use an inhaler ? *

Yes

No

5. Does the student have an Epi-Pen ? *

Yes

No

6. Will your student take medication at school? *

Please contact School office for required Paperwork.

Yes

No

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