Annual Student Health Assessment
Student Information
Full Name
Student ID
Date of Birth
Grade/Year
Contact Information
Parent/Guardian Name
Phone Number
Email Address
Home Address
Medical History
Chronic Medical Conditions
Allergies
Current Medications
Immunization
Are immunizations up to date?
Yes
No
Date of Last Immunization
Physical Assessment
Height (cm)
Weight (kg)
Vision
Hearing
Other Notes
Additional Comments or Special Needs