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School Health Information -Text Only-
5/22/2017

 

M:LHEALTH SERVICESNURSESHARETORMS LETTERMSCHOOL HEALTH INFORMATION.DOC

DIXON UNIFIED SCHOOL DISTRICT

SCHOOL HEALTH INFORMATION

 

 

 

 

 

 

GRADE: TEACHER:

 

 

 

 

 

 

 

ID#

 

 

 

 

 

 

 

 

 

Name:

 

 

 

Birthdate:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Last) (First) (Middle)

Father' s Name:

Mother' s Name:

(Month) (Day) (Year)

Guardian/Step Parent names:

Local Doctor:

 

 

 

 


 

HEALTH HISTORY: Health information that may affect your student's safety and/or education will be given to staff responsible for his/her care. Has your student ever had or does he now have any of the following?

Yes/Date

No

 

Yes/Date

No

 

Insurance Name:

 

 

Concussion

 

 

Bone infections

Date of last physical exam

 

 

Tendency to Faint

 

 

Diabetes

 

 

Convulsions or epilepsy

 

 

Anemia

Date of last dental exam

 

 

Color Blindness

 

 

Bleeding tendency

 

 

Glasses

 

 

Hayfever

Operations or Accidents (Indicate dates)

 

 

Contacts

 

 

Hives or rashes

 

 

Hearing Loss

 

 

Bee sting allergy

 

 

Frequent ear problems

 

 

Drug allergies. If so, name:

 

 

Removal of tonsils &/or adenoids

 

 

 

 

Ear tubes

 

 

 

 

Neck injury

 

 

TB contact

 

 

Asthma

 

 

Chickenpox

 

 

Heart problems

 

 

Whooping Cough

MEDICATIONS: According to the Education

 

 

Rheumatic fever - - ---- -

 

 

Encephalitis

Code, parents are required to inform the school if their child is taking medication regularly.

Name of Medication:

Supervising doctor:

 

 

High Blood pressure

 

 

Scarlet fever

 

 

Hernia

 

 

Mononucleosis

 

 

Loss of kidney

 

 

Skin

 

 

Joint Problems

 

 

 

 

 

Back injury or deformity

 

 

 

 

 

Frequent backaches

 

 

 

Explanation of Yes Answers:

Date: Parent/Guardian: