Health Questionnaire

HEALTH QUESTIONNAIRE

Student Name______Birthdate______Grade______

Last First

We are requesting the following information concerning your child. For your child’s safety, this information will be shared with the appropriate school personnel.

Please contact the health office if your child has health issues requiring staff attention.

Please check your child’s current health issues:

_____Disabilities/ Limitations _____Hearing Loss _____Life-threatening Allergies

_____Vision Problems/ Glasses _____Developmental Delays _____Cancer

_____Seizures _____Moderate-Severe Asthma _____Diabetes

_____Emotional Difficulties _____Other

If you have checked any of the above, please explain:______

______

______

Is your child currently under regular medical care for any conditions? If so, please explain: ______

______

Does your child take medication on a regular basis? Please explain:______

______

If your child will require medication in school, please contact the Health Office.

Physician’s Name______Phone Number______Dentist’s Name______

Phone Number______

Will your child need special services? (Circle if needed) Occupational Therapy Physical Therapy Speech Therapy

Do you have health insurance for your child? (Circle One) Private Medicaid CHP+ None

Vision/Hearing assessments will be done on all K, 1st, 2nd, 3rd, 5th, 7th, and 9th graders and for all new enrollees. Other students may be screened upon request.

ASD health office accesses the Colorado Immunization Information System (CIIS), a confidential web-based system that collects and consolidates immunization information for disease control purposes. The ASD health office uses CIIS as a tool to ensure that your child has the proper immunizations required for school. This includes entering immunization data that the school has on file in a student’s health record which may not be listed on CIIS. If you do not want your child’s immunization data to be entered on CIIS, you may choose to opt out by notifying the health office in writing at the beginning of the school year.

I, the undersigned, do hereby authorize officials of Pagosa Springs School District 50 Jt. to contact directly the persons named on this form, along with appropriate school personnel, and do authorize the named physician/dentist such treatment as may be deemed necessary in an emergency, for the health of said child. In the event physicians, other persons named on this form, or parents cannot be contacted, the school officials are hereby authorized to take whatever action is deemed necessary in their judgment, for the health of said child. I will not hold the school district financially responsible for the emergency care and/or transportation for said child.

Parent/Guardian Signature______Date______

Health Room Hours: Elementary: Monday - Thursday 7:55 - 3:25, Friday 7:55 - 1:25 Middle/Junior High: Monday - Thursday 8:10 am - 3:45 pm, Friday 8:10 am - 1:45 pm High School: Monday - Thursday 8:10am - 3:30pm, Friday 8:10am - 1:30pm rev. 11/16