SCHOOL NURSE INPUT FORM
____ / ____ / ____
Please return completed form to:
Student:
D.O.B.:
Homeroom Teacher:
Grade:
According to health records, what factors (if any) may be
interfering with the student’s ability to learn?
☐ allergies
☐ motor impairment
☐ ADHD
☐ speech/language impairment
☐ visual impairment
☐ frequent ear/nose/throat infections
☐ asthma
☐ hearing impairment
☐ diabetes
☐ migraines/headaches
☐ medication
☐ other:
If on medication(s), please list the type, dosage, and frequency:
Does the medication cause any side effects, which could hinder
school performance? If yes, explain:
Vision Screening
Test:
Hearing Screening
Date:
Test:
Results
Right Eye:
Date:
Results
Left Eye:
Right Ear:
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Left Ear:
© Charley’s Classroom 2019
SCHOOL NURSE INPUT FORM
Does the student:
☐ wear glasses (if yes, for what reason):
☐ have a hearing aid (if yes, in what ear):
☐ use an inhaler
☐ use orthopedic devices (if yes, explain):
☐ other:
Does the student require adaptive physical education?
☐ yes
☐ no
The student has come to see the school nurse for the following reasons:
☐ hygiene issues
☐ medication
☐ illness
☐ complains of illness
☐ physical injury
☐ investigation of abuse
Write a brief statement regarding your contact with this student
during his/her time in school.
Write a brief statement regarding additional contact with this
student’s parent/guardian, as well as other teachers.
Signature of School Nurse
Date
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© Charley’s Classroom 2019