KarenG.

Snyder
Principal

<.AIry

KlmBerlyH. Core

RebekahH. Hunter

ApistantPrincipal

Counselor

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DearCWES
Parent/Guardian,
to be on file
process,
the attachedform is requiredbythe Stateof Alabama
To continuethe registration
at school,it is important
medicalconcerns
for all publicschoolstudents.ln orderto properlyaddress
contactthe schoolif you
andupto dateinformation.Please
that thisform iscompletewith accurate
regarding
the form.
haveanyquestions

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Street
715Sanders
Auburn,Alabama36830

Phone:334-887-494A
Fax:334-887-4772

ALABAMA STATE DEPARTMENT OF EDUCATION

HEALTH ASSESSMENT
RECORD
SchoolYear:

Jors -3"olb

To Parentor Guardian:
regardingyourchild'shealthneeds. The schoolnursemay contactyou for
The purposeof thisform is to providethe schoolnursewith additionalinformation
furtherinformation.The informationrequestedis essentialfor the schoolnurse to meetthe healthneedsof your child,

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Returnto the SchoolNurse)

Nameof Student(Last,First,Middle)

Address(Street)
Number:
HomeTelephone

TeacheriHomeroom

Additional
PhoneNumber:

WorkPhoneNumber:

(Last,FirstMiddle)
Nameof ParenUGuardian

Transportation
E BusRiderBusNumber:

E 9ar Rider

n SpecialNeedsBus

AfterSchool

Part l- HealthInformation
Place your child receives health care:

Yourchild'slnsurancelnformation:

Place your child receivesdental care:

Physician'sName:-

N ALL KIDS

DentisfsName:

Address:

tr Medicaid

Address:

Phone:

Phone:

I Community Health Center

tr Other_

tr CommunityHealthCenter

il HealthDepartment

Health Department

No lnsurance

Private lnsurance

tr HospitalClinic

n HospitalClinic
I

[1 No RegularPlace

No Regular Place

fl PrivateDentist/HMO

D Private Doctor /HMO

PreferredHospital:

Partll- Medical
n Catheter

n GastricTube

n VagalNerveStimulator(VNS)

Medical

/Procedures

uiredat School

n NebulizerTreatments n OxygenSupplement
n Ventilator n Wheelchair

n Tracheostomy

n Walker

AuthorizationForm (one for each medicationor

Medicationsand Proceduresat School requirea PrescriberlParent
procedure)Pleasesee your school nurse.

Pffig$.S

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Page 1

ALABAMA STATE DEPARTMENTOF EDUCATION

RECORD
HEALTH ASSESSMENT

Year:J.O 15 --eQlt"
schoor
P ar tlll- M edicalH
n YESn NO

KNOWNHEALTHPROBLEMS
signature
lf NO,go directlyto thebottomof thepageandprovideparent/guardian
below.
bya physician,
answereachquestion
lf YES,anddiagnosed

n YESn NO
n YESn NO

Attentionpeficit Disorder(ADD)
Disorder(ADHD)
AttentionDeficitHyperactivity
u At Home
Reouires
medication n At school

tr YES n NO

Allergies:
n Food
n Insects

n Environmental
n Medications
Asthma

r YESn NO

Blood/BleedingProblems: aHemophilia,
n Requiresmedication P/easeexplain:

n
n
n
n
n
n

YESn N0
YESg NO
YESn NO
YESI NO
YESo NO
YESa NO

YESa NO
YESn NO
YESn NO
YESn NO
YESn NO

n YESn NO

n Breathingdifficulty

n EPi-Pen

P/easeexplain
Cancer/Leukemia:
Cerebral Palsv: Please explain
Cvstic Fibrosis: P/easeexnlain
Dental Problems:Pleaseexplain:
n MonitorsBloodSugarsat school
Diabetesn Type 1 Diabetes
n Managedwith diet

Emotional/Behavioral/Psvcholooical
: Pleaseexplain:
Genetic/ Rare Disorders: P/easeexplain:
Headaches:Pleaseexplain:
n LeftEar
HearingProblems:n RightEar
n Cochlearlmplant
n Tubes
n Activity restrictions:
Heart Condition:
Pleaseexplain:

a Bothears

a YESI NO

Kidnev/Bladder/ Urinarv Problems: Pleaseexplain:

a No Treatment n WearsBrace
Scoliosis:

YESn NO
YESn NO
YESn NO
YESr NO
YESg NO
YESo NO

Typeof seizure:
$eizures/Convulsions:
nDiastat aKlonopin n Versed
Medications:
PIeaseexplain:

n Hearingloss

a Hearingaid

n Medicationstaken at home:

(HiqhBloodPressure):
P/easeexplain:
Hvoertension
Problems:P/easeexplain:
JuvenileArthritis/BoneJoint

n
n
n
n
n
n

n ReouiresInsulinat school
pump
n Insulin
a Glucagonorder
n Oralmedication

Problems:P/easeexplain:
Gastrointestinal/Stomach

n YESa NO
n YESn NO
n YESn NO
n YESn NO

aOther

nVon Willebrand's,

FrequentNose Bleeds: P/easeexplain

n Type 2 Diabetes
r
n
n
a
a

n Medications

n Other;
n Usesan inhalerat home

r Usesan inhalerat school

n YESn NO

n Hives/rash

n Surgery

n FamilyHistory

a Medicationtakenat home

n Other

SickleCell:n Anemia o Trait

Shunt: s VPshunt P/easeexplain:

SoinaBifida:
Special Diet: P/easeexplain:
n Other
a Wearscontacts
Vision Problems: n Wearsolasses
Other MedicalConditions: P/easeinclude^nv medicationstakenat homeonly.

$ignatureof parent{e}or guadian:i

of school nurse:
Page 2
Rev 5-2014