Student Health Form

Student Health Form

Student Health

Student's Name: 

Birthdate:   

Gender: 

Grade: 

Address: 

City: 

State: 

Zip Code: 

Homeroom Teacher: 

 

Health Information

Doctor's Name:   Phone Number: 

Dentist Name:   Phone Number: 

Hospital Preference: 

Do you have health insurance? 

Do you have dental insurance? 

Does your child have any chronic health conditions? 

If yes, which one(s)*? 

To select multiple conditions use Control key or Command key on Mac. 

   If other, please list: 

*Please contact your school nurse to create a care plan. 

 

Does your student have Allergies? 

  If yes, what kind? 

To select multiple conditions use Control key or Command key on Mac. 

  If Other, please list: 

Does your student have any special restrictions?

Mobility: 

Vision (glasses, contacts): 

Hearing: 

Emotional: 

Speech: 

Other: 

Does your student take medication? 

If yes, list medicine and dosage:

Medicine: 

Dosage: 

 

Medicine: 

Dosage: 

 

Medicine: 

Dosage: 

 

Medicine: 

Dosage: 

Please list any diseases or conditions your student was diagnosed with and the date. Include things such  as whooping cough, chicken pox, hepatitis, epilepsy, nose bleeds, high fevers, fainting spells, Tuberculosis, etc.

Disease: 

Date: 

 

Disease: 

Date: 

 

Disease: 

Date: 

 

Disease: 

Date: 

Please list any operations your student has received:

Type: 

Date: 

Type: 

Date: 

Please list any inuries your student has received:

Type: 

Date: 

Type: 

Date: 

Please list any additional health concerns regarding your student: 

1. IN CASE OF AN EMERGENCY INVOLVING YOUR CHILD, THE EVSC WILL TAKE APPROPRIATE MEASURES TO CARE FOR YOUR CHILD AND THEN CALL THE PARENT/GUARDIAN. IN THE EVENT THE PARENT/GUARDIAN CANNOT BE REACHED, OR IF AN INJURY IS LIFE THREATENING, THE EVSC WILL CALL 911 FOR EMERGENCY HELP AND THEN CALL THE PARENT/GUARDIAN.

2. EVSC WILL KEEP YOUR MEDICAL INFORMATION AS CONFIDENTIAL AS POSSIBLE, BUT FOR HEALTH AND EMERGENCY PURPOSES, INFORMATION ON THIS FORM MAY BE SHARED WITH EVSC PERSONNEL.

NOTE: IF AT THE END OF THE SCHOOL DAY, YOUR CHILD IS ILL OR HAS NOT BEEN PICKED UP AND YOU OR YOUR EMERGENCY CONTACT DESIGNEE(S) CANNOT BE REACHED, EVSC MAY CALL CHILD PROTECTIVE SERVICES IF OTHER ARRANGEMENTS CANNOT BE MADE.         

“I UNDERSTAND THAT AS PARENT/LEGAL GUARDIAN I MAY GIVE AUTHORIZATION FOR THE DISCLOSURE OF MY CHILD’S PROTECTED HEALTH INFORMATION. I UNDERSTAND THAT SUCH HEALTH INFORMATION IS PROTECTED BY FEDERAL REGULATIONS UNDER EITHER THE HEALTH INFORMATION PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) OR THE FAMILY EDUCATIONAL RIGHTS AND PRIVACY ACT OF 1974 (BUCKLEY AMENDMENT) AND MAY NOT BE DISCLOSED WITHOUT EITHER PARENT/LEGAL GUARDIAN AUTHORIZATION UNDER HIPAA OR CONSENT UNDER THE BUCKLEY AMENDMENT. I HEREBY GIVE PERMISSION TO EVSC TO SHARE INFORMATION RELEVANT TO MY CHILD’S HEALTH CONDITION WITH APPROPRIATE SCHOOL PERSONNEL OR HEALTH CARE PROVIDERS WHEN NEEDED TO MEET MY CHILD’S HEALTH AND SAFETY NEEDS. I ALSO GIVE PERMISSION TO EXCHANGE INFORMATION WITH MY CHILD’S PRIMARY HEALTH CARE PROVIDERS FOR THE PURPOSE OF REFERRAL, DIAGNOSIS AND TREATMENT. I UNDERSTAND THAT I MAY REVOKE THIS AUTHORIZATION AT ANY TIME BY NOTIFICATION IN WRITING TO EVSC, BUT IF I DO, IT WILL NOT HAVE ANY EFFECT ON THE ACTIONS OF THOSE REPRESENTING EVSC PRIOR TO RECEIVING THE REVOCATION.”                                                                                   

THIS AUTHORIZATION EXPIRES ONE YEAR AFTER THE DATED SIGNATURE.

Parent Signature (Please type name): 

Date:   



Security Measure