School Entry Health Screening Form
Student Information
Name
Date of Birth
Grade
School Year
Parent/Guardian Information
Name
Phone Number
Address
Email
Health History
Has your child had any of the following? (Check all that apply):
Asthma
Allergies
Diabetes
Seizures
Heart Condition
Other
If other, please specify
Current Medications
Special Needs/Health Concerns
Immunization
Are your child's immunizations up to date?
Yes
No
If no, explain
Screening
Height
Weight
Vision
Hearing
Physician/Clinic Name
Physician/Clinic Phone
Parent/Guardian Signature
Name
Date