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Wapello Community School District Pre/Elementary/Middle/High – School


STUDENT INFORMATION AND HEALTH HISTORY UPDATE

Student Name _______________________________________ Sex [ ] M /[ ] F Grade _____ DOB _________

Parent Name ________________________________________ Phone: ______________________________

Emergency Contact __________________________________ Phone: ______________________________

Physician: _________________________________________ __ Phone: __________________ ____________

Dentist: ___________________________________________ Phone: ______________________________

Insurance: None ________ Private ________ Medicaid ________ Other ________

I give permission for my child to have acetaminophen (Tylenol), ibuprofen, cough drops, antacid tablets

as determined by the school nurse and/or personnel. Yes ________ No ________

PLEASE CHECK IF THE STUDENT HAS HAD DIFFICUOTY WITH ANY OF THE FOLLOWING

GIVE DATES AND ADDITIONAL INFORMATION UNDER COMMENTS

( ) ADD/ADHD

( ) Asthma

( ) Behavior

( ) Bleeding

( ) Bone Problem

( ) Bowel/Bladder

( ) Chicken Pox

( ) Diabetes

( ) Hearing

( ) Heart

( ) Infections

( ) Kidney

( ) Seizures

( ) Speech

( ) Surgery

( ) Vision

( ) Other _______________ ( ) Comments ___________________________

Does your child have allergies to medicine, food, latex, or insect bites? Yes ________ No _______

To what? _______________________________ What happens? __________________________________ 

Treatment _________________________________________________________________________________________

Is your child being treated or evaluated for any health conditions: Yes ________ No ________

List conditions ______________________________________________________________________________

Is your child on any mediations or treatments: Yes ________ No ________

Name of mediations or treatments _____________________________________________________________

Does your child need medication during school hours? Yes ________ No ________

* If yes, please contact the school nurse ASAP to make arrangements.

Has your child ever been examined by an eye doctor? Yes ________ No ________

Date of last exam _______________________________ Were glasses prescribed? Yes ______ No ______

If your child wears glasses/contact lenses, when was the prescription last changed? ____________________

Has your child had any emotional upsets since school ended in May? Yes ________ No ________

(recent move, death, separation, divorce)

What is the date of his/her last dental exam? _______________________________

What is the date of his/her last physical: _______________________________

Has your child ever had a “Medical Action Plan” from the school nurse: Yes ________ No ________

List reason

_________________________________________________________________________________________

I verify that all of the information provided on this form is correct.

This information may be shared with school personnel on a “need to know” basis.

_________________________________________________ _____________________

Parent Signature                                                       Date