HEALTH INFORMATION – 2017-2018 (NEW students) This information will be reviewed and maintained in confidential manner by the School Nurse assigned to your student’s school.
STUDENT NAME: ___________________________________________________ First
EARLY CHILDHOOD HEALTH HISTORY Were there any significant problems during the pregnancy, labor or delivery? No Yes If yes, is this concern a current issue? No Yes If yes, please explain? _____________________________________________________________ _________________________________________________________________________________________________
PLEASE CHECK ALL HEALTH CONDITIONS THAT APPLY TO YOUR STUDENT. IF A HEALTH CONDITION PERTAINING TO YOUR STUDENT HAS A COMMENT FIELD, PLEASE PROVIDE ADDITIONAL INFORMATION IN THE FIELD. Allergies – Life Threatening – Comment required Life threatening allergy – Dairy Comment:________________________________________ Life threatening allergy – Food List Food(s):______________________________________ Life threatening allergy – Insect Sting Comment:________________________________________ Life threatening allergy – Latex Comment:________________________________________ Life threatening allergy – Peanut Comment:________________________________________ Life threatening allergy – Tree Nuts Comment:________________________________________ Life threatening allergy – Other List:____________________________________________ Life threatening allergy – Unknown Comment:________________________________________ Allergies – Comment required where indicated Animal Environmental/Seasonal Food List Food(s):___________________________________________________________ Insect Sting Latex Medication List Medication(s):_______________________________________________________ Non-Specific Other Conditions – Comment required where indicated ADD/ADHD – Name of medication: ___________________________________________________ Alopecia Arthritis Juvenile Asthma Comment:____________________________________________ Autism Spectrum Comment:____________________________________________ Auto-Immune Condition Comment:____________________________________________ Blood Disorder Comment:____________________________________________ Cancer Comment:____________________________________________ Celiac Disease 620 Wilcox Street
1 of 3
Castle Rock, Colorado 80104
303-387-0100 Revised 10/25/2016
HEALTH INFORMATION – 2017-2018 (NEW students) Cerebral Palsy Chromosomal Anomalies Crohn’s Disease Cystic Fibrosis Diabetes Down Syndrome Emotional Condition Encopresis Enuresis Fetal Alcohol Syndrome Frequent Headaches Gastrointestinal Disorder Head Injury/Concussion Hearing Impaired Heart Condition – No Restriction Heart Condition – Restrictions Hepatitis B Carrier Hepatitis C Carrier History of Injuries Hypoglycemia Immune Compromised Kidney Problem Lactose Intolerant Long QT Syndrome Migraine Headaches Myalgia Myositis Fibromyalgia Neurologic Disorder Nosebleeds Orthopedic – Physical Limitation Orthopedic – No Restrictions Other Paraplegia Quadriplegia Scoliosis Seizure Disorder Shunt/Hydrocephalus Skin Condition Syncopal Episodes Syndrome Thyroid Condition Tourette Syndrome Tracheostomy Traumatic Brain Injury Urinary Problem 620 Wilcox Street
HEALTH INFORMATION – 2017-2018 (NEW students) Wears Glasses/Contacts Vision Impaired Comment:____________________________________________ Von Willebrand’s Disease Wolff Parkinson White Syndrome
ADDITIONAL INFORMATION List any illness, hospitalization, surgery, accidents your student had in the past year. None _________________________________________________________________________ Date: ________________ _________________________________________________________________________ Date: ________________ _________________________________________________________________________ Date: ________________ List any emotional, social or other conditions that might affect your student’s school performance. ___________________________________________________________________________________ None Is your student currently taking any medication, including over-the-counter medication? No
If your student will need to be given medication at school, a Provider Medication Authorization Form for each medication will be needed. If your student is a middle school student and will self-carry prescription medication, a Permission to Carry Form must be completed for each medication. High school students may self-carry and self-administer one-day supply of medication, carried in a pharmacy labeled container. Is your student currently receiving alternative therapies (acupuncture, homeopathic, herbal, biofeedback, etc)? No
Yes
If yes, please explain: _________________________________________________________________________ Is there anything else you would like us to know about your student?
Health Information Form 17-18 102516.pdf. Health Information Form 17-18 102516.pdf. Open. Extract. Open with. Sign In. Main menu. Displaying Health ...
There was a problem previewing this document. Retrying... Download. Connect more apps... Try one of the apps below to open or edit this item. 1718 Proration ...
There was a problem previewing this document. Retrying... Download. Connect more apps... Try one of the apps below to open or edit this item. IAC Application ...
Page 1 of 3. 1. Kaua`i Community College 3â1901 Kaumualii Highway * Lihue, HI 96766 [email protected] (808) 245â8360. For use during Fall 2017, Spring 2018 & Summer 2018 Based on tax year 2015. Kaua`i Community College Financial Aid. 2017â18
There was a problem previewing this document. Retrying... Download. Connect more apps... Try one of the apps below to open or edit this item. Health Information Form 2016-17.pdf. Health Information Form 2016-17.pdf. Open. Extract. Open with. Sign In.
... members are protected against this crime at no cost and no need to sign up. Just call the phone number below if you ever find yourself a victim of identity theft.
Sign in. Loading⦠Page 1. Whoops! There was a problem loading more pages. Retrying... 1718-Cello.pdf. 1718-Cello.pdf. Open. Extract. Open with. Sign In.
Payment will be forfeited if materials are not retrieved. Requestor Signature: Date: OFFICIAL USE ONLY: Date Routed for review: Approved: Denied: Type of Request: ( ) Routine ( ) Multi-Departmental ( ) Extraordinary ( ) Waiver of fees approved: Numbe
May 18, 2017 - Details student. Name of intern. Kieran Bilau. ESP class. LP16-12. Contact details placement. Name of clinic. Centre des Savoyances. Contact ...
2017-2018 school year. THIS SIDE IS CONCERT ORCHESTRA MATERIALS!! Concert Scale: 2-octave e melodic minor scale. Excerpt: Fletcher â Folk Tune and ...
There was a problem previewing this document. Retrying... Download. Connect more apps... Try one of the apps below to open or edit this item. Health Appraisal ...
May 28 Memorial Day. First Day of School August 28. Holidays In Blue. Last Day of School June 7. General Information. Student Days = 146. Staff Days = 158.
Aug 18, 2017 - In the interest of your children's safety, and in accordance with the. guidelines of the EDB and Hong Kong Observatory, lessons will be. cancelled in the event of adverse weather conditions. No refunds will be given. Where possible, pa
There was a problem previewing this document. Retrying... Download. Connect more apps... Try one of the apps below to open or edit this item. CAS 1718 ...
Page 1. Whoops! There was a problem loading more pages. Retrying... Supply List 1718.pdf. Supply List 1718.pdf. Open. Extract. Open with. Sign In. Main menu.
