Blank School Health Record
I. STUDENT INFORMATION
Field | Details |
|---|
Name: | |
Date of Birth: | |
Grade/Year: | |
Gender: | |
Address: | |
Parent/Guardian Name(s): | |
Contact Number: | |
Email Address: | |
Emergency Contact Name: | |
Emergency Contact Number: | |
II. MEDICAL HISTORY
Condition/History | Yes/No | Additional Details |
|---|
Allergies | | |
Asthma | | |
Diabetes | | |
Epilepsy/Seizures | | |
Vision Problems | | |
Hearing Problems | | |
Other Chronic Conditions | | |
Past Surgeries or Injuries | | |
III. IMMUNIZATION RECORD
Immunization | Date Given | Booster (if applicable) |
|---|
MMR (Measles, Mumps, Rubella) | | |
DTP (Diphtheria, Tetanus, Pertussis) | | |
Hepatitis B | | |
Varicella (Chickenpox) | | |
Polio | | |
IV. CURRENT MEDICATIONS
Medication Name | Dosage | Time Administered | Notes |
|---|
| | | |
V. PHYSICAL ASSESSMENT
Metric | Assessment Date | Results/Notes |
|---|
Height | | |
Weight | | |
Vision Screening | | |
Hearing Screening | | |
Dental Screening | | |
VI. CONSENT AND SIGNATURES
Parent/Guardian Signature: | Date Signed: |
|---|
| |
School Nurse/Physician Signature: | Date Signed: |
|---|
| |
For questions or updates to this record, please contact:
[YOUR NAME], [YOUR EMAIL]
[YOUR COMPANY NAME]
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