CONCORD-CARLISLE REGIONAL SCHOOL DISTRICT

HIGH SCHOOL STUDENT HEALTH SCREENING FORM

                                                                                                           

 

(To be completed by Parents/Guardians/Students and returned to school with record of physical examination on entering school)

 


(In Answering The Following Questions, Please Circle YES or NO)

 

Name of Student: ______________________________________Grade: ____________ Date: ___________

 

1. Has the student had a physical examination in the last year? (If YES, give                    YES            NO

Date of exam and doctor’s name)________________________________

2. Has your child ever had an allergic reaction? If YES, please describe what happened.   YES            NO

            ________________________________________________________________

3. Is your child allergic to bee stings?                                                                              YES            NO

4. Does your child have asthma?                                                                                    YES            NO

5. Is your child susceptible to frequent colds and throat infections?                                   YES            NO

6. Has your child had any ear trouble or problems with hearing?  If YES,  please describe.        YES            NO

7. Has your child any eye trouble or problems with seeing? If YES,  please describe.                     YES            NO

8. Does your child wear glasses or contact lenses? Date of last exam_________             YES            NO

9. Does your child see a dentist and/or orthodontist? If YES, please state name and          YES            NO

     any special problems. ______________________________________________

      ________________________________________________________________

10. Does your daughter have any menstrual problems? If YES, please describe.               YES            NO

     _________________________________________________________________

     _________________________________________________________________

11. Does your child have convulsions or seizures?                                                           YES            NO

12. Does your child have a heart condition?                                                                     YES            NO

13. Has your child had any marked changes in weight recently?                                       YES            NO

14. Does your child frequently complain of abdominal pain?                                             YES            NO

15. Does your child have frequent headaches?                                                                YES            NO

16. Is your child taking any medications, tablets or vitamins now?                         YES            NO

17. Does your child have any present physical limitations that may require program           YES            NO

     modifications or restrictions?

There are health concerns I would like to address                                                            YES            NO

 

_____________________________________                                  ___________________________________

Signature of Parent/Guardian/Student                                         Date

 

CALLS, DISCUSSIONS, CONCERNS AND QUESTIONS FROM THE FAMILY TO THE HEALTH SERVICES STAFF RELATING TO THE STUDENT’S HEALTH ARE WELCOME AND ENCOURAGED. YOUR HEALTH SERVICES STAFF PEOPLE CAN BE REACHED AT 978-318-1417 extension 121.                                               

 

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