Free Student Health Checklist Format Template

STUDENT HEALTH CHECKLIST FORMAT

Student Name: [Enter Student Name]
Grade/Class: [Enter Grade/Class]
Date of Birth: [Enter Date of Birth]
Date of Checklist: [Enter Date]

Personal Health Information

Category	Details
Allergies	[Specify Allergies or Write None]
Medications	[List Medications or Write None]
Chronic Conditions	[Specify Chronic Conditions or Write None]
Vaccination Status	[Up-to-date/Pending] - Specify Pending Vaccines
Recent Illness/Injury	[Describe Recent Illness/Injury or Write None]

Daily Health Monitoring

Health Aspect	Checked (✔)	Comments
Temperature		[Add Temperature Reading or Notes]
Symptoms of Illness		[Specify Symptoms or Write None]
Energy Levels		[Describe Observation]
Appetite		[Describe Eating Habits]

Hygiene Practices

Hygiene Aspect	Status (✔)	Comments
Regular Handwashing		[Additional Notes]
Personal Cleanliness		[Describe Hygiene Habits]
Proper Mask Usage (if needed)		[Describe Mask Compliance]

Physical and Mental Well-being

Aspect	Checked (✔)	Notes/Comments
Physical Activity		[Describe Physical Activities]
Sleep Hours (8–10 hours)		[Specify Average Sleep Duration]
Emotional/Mental State		[Describe Emotional/Mental State]

Health Appointments

Appointment Type	Date	Status
Doctor Checkup	[Enter Date]	[Completed/Pending]
Dentist Checkup	[Enter Date]	[Completed/Pending]
Specialist Visit	[Enter Date]	[Completed/Pending]

Parent/Guardian Notes

Additional Observations:
[Enter Any Observations or Write None]

Health Checklist Certification

Checked by: [Enter Name]
Position: [Enter Position]
Date: [Enter Date]

Checklist Templates @ Template.net