Free Student Health Checklist Format Template
STUDENT HEALTH CHECKLIST FORMAT
-
Student Name: [Enter Student Name]
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Grade/Class: [Enter Grade/Class]
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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]
