Health and Medical Needs Assessment
for Special Education
Student Name
Date of Birth
School
Grade/Class
Parent/Guardian Name
Contact Number
Medical Diagnosis / Conditions
Primary Diagnosis
Other Diagnoses
Current Medications
Allergies (Food, Medication, Environmental)
Emergency Action Plan Required?
Yes
No
Health Care Needs at School
Treatments or Medical Procedures Needed at School
Special Equipment/Assistive Devices
Mobility/Accessibility Needs
Nutritional/Dietary Needs
Additional Information
Other Concerns/Comments
Assessment Completed By
Date