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Wheelerschool.org

The Wheeler School Health Center
CONFIDENTIAL
STUDENT HEALTH HISTORY – TO BE COMPLETED BY PARENT(S)/GUARDIAN(S)
New Students: Complete side 1 and side 2.
Returning Students: Side 1 must be completed. Complete Side 2 if any new health issues.

Student Name ___________________________________________________ Grade ______
(Last)
Medication History
NO Medications
Medications taken daily (prescription and non prescription medications). Please note drug name, dose and time taken. ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Permission to administer over the counter medications
No medications may be administered by the school nurse without prior authorization. Please
check boxes, below, with “yes” or “no.” (For students in Nursery through Grade 3, a
parent/guardian will be called before any medication is administered.)
The following medications may be administered by the school nurse to my child during school, if needed: no Tylenol (acetaminophen)
no Benadryl
no Advil (ibuprophen)
no Claritin
no Aleve (naproxen)
no Throat lozenges
no Calamine or Calagel
no Rolaids
no Hydrocortisone 1%cream
no Insect repellent
no Sunscreen
no Dramamine
no Visine Pure tears
Release of Information
The school nurse has permission to release health information on a need-to-know-basis to
school personnel (such as Head of School, Division Head, Teacher, School Counselor).
____ yes ____no
IV. Returning Students:
NO new health problems
NEW health problem(s) - Please complete side 2 ►
Parent/guardian signature _____________________________________ The Wheeler School Health Center
Please note if student has experienced (returning students – update new information
only):
____Bone fracture
Allergy History
Please note all drug, food and /or environmental allergies, and reaction(s), if known:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Health History
Please note any health problem(s), long-term health condition(s) or learning
difference(s) that may affect behavior or health at school:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

Has student been hospitalized in the last year?
___no ___yes
If yes, please note date and reason for hospitalization:
___________________________________________________________________________
___________________________________________________________________________
Please note any psychological/emotional health issue(s) that may affect behavior or
health at school:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

Source: http://www.wheelerschool.org/ftpimages/362/download/Parent%20health%20history%20Form%202013-14.pdf

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