Ascension School - REQUIRED Annual Student Health Information Form

Please complete the form below. Required fields marked with an asterisk *

Student First/Middle/Last Name:*

Answer required for "Student First/Middle/Last Name:"

Student DOB:*

Answer required for "Student DOB:"

Student Grade:*

Answer required for "Student Grade:"

Student Gender:*

Answer required for "Student Gender:"

Male

Female

Doctor Name:*

Answer required for "Doctor Name:"

Doctor Phone:*

Answer required for "Doctor Phone:"

Dentist Name:*

Answer required for "Dentist Name:"

Dentist Phone:*

Answer required for "Dentist Phone:"

Specialist Name(s):

Answer required for "Specialist Name(s):"

Specialist(s) Phone:

Answer required for "Specialist(s) Phone:"

History/ Medical Diagnosis - Please check any and all that apply:*

Answer required for "History/ Medical Diagnosis - Please check any and all that apply:"

ADHD

*Asthma

Autism

*Diabetes

Heart/ Lung

*Seizure Disorder

*Allergies

None

*Medical diagnoses that impact your child's health and safety during the school day and/ or require treatment or accomodations, such as severe food allergies, asthma, etc., will need an Action/ Care Plan completed by the physician. This includes Asthma, Diabetes, Seizure Disorder, and Allergies of the options above.

If you checked "Seizure Disorder" above, please provide date of last seizure.

Answer required for "If you checked \"Seizure Disorder\" above, please provide date of last seizure."

If you checked "Allergies" above, please specify below, including drug allergies, food allergies, insect/ bee allergies, or other alleries:

Answer required for "If you checked \"Allergies\" above, please specify below, including drug allergies, food allergies, insect/ bee allergies, or other alleries:"

Please select if any of the below apply to your child:*

Answer required for "Please select if any of the below apply to your child:"

Hearing Loss / Aids

Glasses / Contacts

Anxiety

Behavioral Concerns (please explain below)

Concerns that might affect performance at school (please explain below)

NO KNOWN HEALTH PROBLEMS

If you checked "Hearing Loss / Aids" above, please indicate left ear, right ear, or both.

Answer required for "If you checked \"Hearing Loss / Aids\" above, please indicate left ear, right ear, or both."

If you checked "Glasses / Contacts" above, please indicate distance or near.

Answer required for "If you checked \"Glasses / Contacts\" above, please indicate distance or near."

If you checked "Behavioral Concerns" or "Concerns that might affect performances at school" please explain here:

Answer required for "If you checked \"Behavioral Concerns\" or \"Concerns that might affect performances at school\" please explain here:"

List all medications, reasons, dosage, and time given:

Answer required for "List all medications, reasons, dosage, and time given:"

* Any medication to be administered at school requires the completion of Authorization of Medicaiton Administration in School Form.

Parent/ Guardian Name:*

Answer required for "Parent/ Guardian Name:"

Parent/ Guardian Signature:*

Signature Required

Please fix the highlighted areas below before submitting.

Ascension School - REQUIRED Annual Student Health Information Form