HEALTH SERVICES
STUDENT HEALTH INVENTORY
Student Name Date of Birth Grade
Please check any of the following physician diagnosed diseases or conditions that apply to your child:
____My child has no known health condition or allergies
____ADHD/ADD ____Asthma ____Bladder/Kidney Disease ____Blood Disorder
____Bone/Joint Disease ____Bowel/GI Condition ____Diabetes ____Dietary Needs
____Hearing Impaired ____Heart Condition ____High Blood Pressure ____Mental Health Condition
____Migraine Headaches ____Seizures ____Sickle Cell ____Speech Condition
____Vision Impaired ____Other
1. If any of the health conditions listed apply to your child, please provide any additional information:______
______
2. Does your child have a severe allergy to any of the following: Food______Insect Bites______Latex______Medication______If so, is emergency medication required? Yes____ No____ If yes, please provide name of medication and describe reaction:______
______
A Physician’s Statement Form is required to be filled out and signed by the medical provider, in order to make any necessary dietary modifications. Additional authorization forms will also be needed for emergency medication.
3. Please list any recent serious illnesses, injuries, surgeries/hospitalizations or current medical care:______
______
______
4. Is your child taking any medication at this time? Yes____ No____ If yes, indicate the medication, dose and reason for medication:______
Will it be given at school? Yes____ No____ If so, additional authorization forms will be required.
5. Does your child require the use of any special equipment/aids in the classroom? Yes____ No____ If so, please explain:
______
______
6. Please list any specialized procedures your child requires during the school day (catheterization, tube feedings, glucose monitoring, trach care, etc…) Additional authorization forms will be necessary:______
______
In the event of an emergency situation and I cannot be reached, I, the undersigned do hereby authorize officials of New Caney ISD to call the emergency contacts provided to render such treatments as may be deemed necessary for the care, safety and welfare of my child. In the event parents, nor emergency contacts can be reached, school officials are hereby authorized to take whatever actions is deemed necessary for the care, safety and welfare of my child. I hereby authorize the aforementioned health related information to be released to the appropriate school personnel for the care, safety, and welfare of my child.
Signature of Parent or Guardian Date
______
THIS SECTION TO BE COMPLETED BY SCHOOL NURSE
Health Inventory Review by Campus Nurse completed on ______(date).
Campus Nurse Printed Name: ______Signature ______
HEALTH SERVICES
6/15