Mecklenburg County
Health Department
STUDENT HEALTH HISTORY AND IMPORTANT INFORMATION
Part of the School Nurse’s role is to assess the student’s health needs and to assist the student,
his/her family and the school community to meet the health, developmental, educational and
emergency needs of the student.
In order for your school nurse to best serve your child, please fill out the following information
and then return it to the school as soon as possible.
Student’s Last Name
First Name
Student’s Home Address
Mother/Guardian Name
Date of Birth
Home Phone
Phone Number
Grade
Parents Work Phone
Father/Guardian Name
Student’s Health Insurance is: (Please check one)
( ) HMO
( ) Regular Insurance
( ) Medicaid
Phone Number
( ) Medicaid/HMO
Student has a history of: (please check those that apply)
_____ Diabetes
_____ Autoimmune disease _____ Bone/Muscle Problems
_____ Hearing Loss
_____ Sickle Cell Disease
_____ Visually impaired
_____ Kidney Disease
_____ Asthma
_____ High Blood Pressure
_____ Seizures
_____ Eating Disorder
_____ Rheumatoid arthritis
_____ Cancer
_____ ADD/ADHD
_____ Allergies: (type)_______________________________________________________
_____ Heart trouble: (type)____________________________________________________
___ Other (please describe) ____________________________________________________
_____________________________
Reviewed by
Date
_______________________________________
Parent/guardian Signature
Date
If your child takes medication at school whether prescription or over-the-counter, a Medication
Authorization Form needs to be completed, signed by both the parent and the doctor and on file
at school. If you have questions and/or concerns, your School Nurse can be contacted through
your child’s school.
Rev 5-03 mp
CI 2