Fillable STUDENT HEALTH INVENTORY

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STUDENT HEALTH INVENTORY

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School:______________________ Springfield Public Schools Student #:___________
Grade:_______________________
STUDENT HEALTH INVENTORY
Student’s Name:___________________________________________________Date of Birth:_________________ Sex:_____________
Emergency Contact Name: ___________________________________________ Phone Number: _______________________________
Emergency Contact Name: ___________________________________________ Phone Number: _______________________________
Has student previously attended another Public School? ____No ____Yes__________________________________________
Name of school OR previous program
For concerns, please circle “yes” or “no” and if yes, provide a comment:
Additional information regarding your child’s health:___________________________________________________________________
Does your child take medication (prescription or over-the-counter) for any of the above concerns?
______No _____Yes(Name of medication(s)/reason for taking) ____________________________________________________________
***Medication to be taken at school requires additional forms. Contact school nurse for policy guidelines.
Does your child require any special procedures? (catheterization, ostomy care, suctioning, tube feeding, diapering, etc?)
______No ______Yes(describe)_____________________________________________________________________________________
Provider
Name
Approx. date of last visit
Pediatrician/Primary Care Provider_____________________________________________________________________________________
Specialist_________________________________________________________________________________________________________
Specialist ________________________________________________________________________________________________________
Hospital Preference_________________________________________________________________________________________________
Dentist/Orthodontist________________________________________________________________________________________________
Outside Counseling; PT; OT; or Speech_________________________________________________________________________________
Case Worker (if applicable)_________________________________________________________Phone Number______________________
Health Insurance ____None ____Private Health Insurance ____Medicaid (MoHealthNet)________________________
Number
SPECIAL EDUCATION or SERVICES student receives: ___IEP ___504 ___Dietary 504 ___Modified PE ___PT ___OT
Transportation to/from school: ____Walk ____Car ____Bus (#________) _____Daycare (___________________)
Name of daycare/program
I understand if my child is injured or becomes seriously ill and the school nurse, principal or designee cannot notify me by telephone, they
will secure medical attention for my child and use ambulance services if necessary. I also understand that I will be responsible for the costs
of such medical services and care.
Signature of legal parent/guardian____________________________________Relationship___________________Date_____________
Revised 3/13/17
CONCERN
YES
NO
COMMENTS
YES
NO
COMMENTS
ADD/ADHD
Y
N
Developmental Delay
Y
N
Allergies (food, insects,
latex, other)
Y
N
Diabetes
Y
N
Allergies (environmental,
seasonal, meds)
Y
N
Genetic Disorder
Y
N
Assistive Devices
Y
N
Head Injury/Concussion/TBI/ABI
Y
N
Asthma (history or under
treatment)
Y
N
Hearing (aids/FM device)
Y
N
Autism
Y
N
Heart (not innocent murmur)
Y
N
Behavioral and/or Emotional
Y
N
Migraines
Y
N
Bladder
Y
N
Neuromuscular (cerebral palsy,
muscular dystrophy)
Y
N
Bleeding
Y
N
Nutrition (feeding issues)
Y
N
Bone or Joint Problems
Y
N
Seizures (history of or under
treatment)
Y
N
Bowel
Y
N
Sickle Cell Disease or Trait
Y
N
Cancer (history or under
treatment)
Y
N
Speech
Y
N
Cystic Fibrosis
Y
N
Surgeries: (please list)
Y
N
Dental
Y
N
Vision (glasses/contacts/blind)
Y
N
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STUDENT HEALTH INVENTORY

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Completed 8 June 2021

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