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