Health Form

Student Name

First Last

Date of Birth

Grade

Gender

When child is ill or injured, please list which parent/guardian the school should notify first. Please list in preferred order of contact.

#1) Parent/Guardian Name

First Last

#1) Parent/Guardian Relationship

#1) Parent/Guardian Cell Phone

#1) Parent/Guardian Work Phone

#2) Parent/Guardian Name

First Last

#2) Parent/Guardian Relationship

#2) Parent/Guardian Cell Phone

#2) Parent/Guardian Work Phone

In case parent can’t be reached, please contact the individual below: This person has agreed to assume this responsibility and is local.

#3) Contact Name

First Last

#3) Contact Relationship

#3) Contact Cell Phone

#3) Contact Work Phone

Child's Doctor

First Last

Phone

Preferred Hospital

Child's Dentist

First Last

Phone

Orthodontist

Type of Health Insurance

Private
Title 19/Medicaid
Hawk-I
No Health insurance

HEALTH CONCERNS

Mark the box if your child has a history of the following conditions. Mark additional information as needed. Additional forms may need to be completed by your physician (marked with *). Forms available on school website.

Asthma or Reactive Airway Disease

Yes
No

Asthma or Reactive Airway Disease

Yes
No

Triggers

Exercise
Colds/Allergies
Animals
Smoke
Weather
Food
Dust/Air
Other

Will the inhaler ever be needed at school?

No
Yes -- Asthma Action Plan*

Will the student carry their own inhaler?

No
Yes -- Authorization to Carry/Self-Administer*

Diabetes

Type 1
Type 2
No

Does the student use insulin?

No
Yes -- Diabetic Medical Management Plan*

Does the student have glucagon?

No
Yes

If YES...does the student need glucagon at school?

No
Office
Backpack
Locker

If checked locker, what's the student's locker #?

Seizure Disorder

Yes -- Seizure Action Plan*
No

Does the student have rescue meds

Yes
No

If YES...does the student need rescue meds at school?

No
Office
Backpack
Locker

If checked locker, what's the student's locker #?

Allergies [Food, Insect, Seasonal, Medication]

Yes
No

Is the student at risk for anaphylaxis at school?

Yes -- Allergy & Anaphylaxis Emergency Plan*
No

Will the student need a lunch accommodation?

Yes -- Diet Modification Form*
No

Does the student have an EpiPen?

Yes
No

If YES...does the student need an EpiPen at school?

No
Office
Backpack
Locker

If checked locker, what's the student's locker #?

List allergies below:

List "other" allergies

List medications for allergies

Heart Condition/Murmur/Disease/Surgery

Yes
No

If Yes, please explain:

Activity Restrictions (ongoing)

Yes
No

Doctor’s note required for explanation*

If Yes, please explain:

ADD / ADHD

Yes
No

Emotional and/or Behavioral Diagnoses

Yes
No

Anxiety

Yes
No

Depression

Yes
No

List other emotional and/or behavioral diagnoses

If have any emotional and/or behavioral diagnoses, does it require medication?

Yes
No

List medication towards the end of the form

Headaches / Migraines

Yes
No

If Yes, please explain

Bowel/Bladder Concerns or Incontinence

Yes
No

If Yes, please explain

Assistive Equipment

No
Glasses/Contacts
Hearing Aids
Wheelchair
Other

List other assistive equipment

History of Concussion / Head Injury

Yes
No

If Yes, please explain

Other medical history or current medical/developmental concerns that could affect child’s education

Medications

List ALL medications taken regularly at home or at school. Please specify frequency and reason for use.

Medication | Dose | Time(s) Taken | Frequency | School / Home Reason for use:

Permission...

I give permission to the school to administer over-the-counter medications (such as but not limited to acetaminophen, ibuprofen, antibiotic ointment or cough drops) to my child if supply is available. Medication will only be given per label indication and dosed according to age.
I do NOT give permission to the school to administer any medications the school has available.

Consent*

I understand that any medication sent from home to be taken at school needs to be in the original labeled container and a Medication Authorization Form must be completed in order for it to be given. I understand that students may not carry any medications. I give permission to the school to contact my child’s doctor/dentist to confirm appointments and authorize medications/plans of care as necessary. If an emergency should arise, I agree to assume full financial responsibility for my child’s medical care. I understand it is my responsibility to update any of the above information as needed. I understand this information is confidential but may be shared with appropriate school personnel when necessary for the child’s safety or education.

Signature*

CAPTCHA

2020-2021 GLR Student Health Registration

HEALTH CONCERNS

Medications