Special Needs Student Health Information Form
Student Information
Student Name
Date of Birth
Grade/Class
School Year
Parent/Guardian Information
Parent/Guardian Name
Contact Number
Email Address
Medical Information
Diagnosis/Condition
Physical Needs/Assistance Required
Allergies (Food, Medication, etc.)
Medications Taken (include dosage and timing)
Medical Devices Used (e.g. wheelchair, hearing aid)
Doctor's Name
Doctor's Contact Information
Emergency Contact
Name
Relationship
Phone
Additional Information
Other Information School Staff Should Know