School Student Health Risk Assessment Form
Student Information
Full Name
Student ID
Date of Birth
Grade/Class
Contact Information
Parent/Guardian Name
Phone Number
Email
Address
Medical History
Chronic Illnesses (if any)
Allergies (if any)
Medications Being Taken
Risk Assessment
Have you experienced any illness in the past month?
Yes
No
Have you been hospitalized in the past year?
Yes
No
Other Health Concerns