SCHOOL NURSE SCREENING AND EMERGENCY CONTACT
STUDENT’S NAME: _________________________________________
EMERGENCY NUMBERS ___________________
LAST FIRST ___________________
TEACHER’S NAME: _________________________________________
GRADE:___________
Health screening and observation of students K-12 is a legal responsibility
charged to teachers and school nurses, I understand that my child may
participate in routine screening procedures such as height, weight, vision,
hearing, dental, communicable diseases, and blood pressure. It is important that
the school be aware of any special health problems that your child may have.
Please check conditions below:
� Known allergies to drugs, bee
Medications: ______________
stings, environment, or foods
� Bleeding Disorders
(Please list:
Type: ____________________
____________________)
Medications: ______________
� Diabetes
� Asthma
Insulin dependent ? Yes or No
Date of last attack ________
� Seizures
Medications: ______________
Date of last seizure: _________
� Orthopedic Problems
� Sickle Cell Disease
Describe: ______________
� Vision Problems
� Kidney Problems
Type: _________________
Glasses ? Yes or No
Contacts ? Yes or No
� Learning Disorders
� Hearing Problems
Special Needs: _________
Hearing Aid ? Yes or No
Medications: ___________
� Heart Problems
� Other Conditions and/or
Medications Routinely
Taken: _____________________________________
Should it be necessary for my child to receive medications at school, other than
the nurse’s orders below, I understand that my doctor and I are to complete a
special form to be obtained from the school secretary.
My child has ______Health Insurance, ______Accident Insurance,
_______Medicaid, or ______Dental Insurance