Carrollton-Farmers Branch Independent School District

Annual Student Health Information Form
To be completed by parent/guardian of student – If your child has an acute or chronic medical condition, or any medical changes
that occur during the year, it is your responsibility as the parent/guardian to notify the school nurse and update this information.
Student’s Name______________________________________ M / F Grade/Teacher_________________________ School ID________
Last

First

Middle

Address________________________________________________

Birth Date_________________

Mother’s Name ________________________ Home #_______________________Cell #_______________________Work #_______________
Father’s Name _________________________Home #_______________________Cell #________________________ Work # _____________
In the event that a parent cannot be reached, the following people have permission to pick up this student from school if they are sick or injured: (We
cannot release your child to anyone who is not listed below.)

Name_________________________Cell #___________________ Work# ___________________Home #___________________
Name ________________________ Cell #___________________Work #___________________ Home #___________________
Name ________________________ Cell #___________________Work #_________________ __Home # ___________________
Health Condition: Please answer ALL questions associated with your child’s condition(s):
My child has NO KNOWN HEALTH CONDITIONS and does not require any medication at home or school.
Abdominal Issues:
Due to: ____Irritable Bowel Syndrome ____Gastric Reflux
____Crohn’s Disease _____Colitis ____Constipation
____ Other:__________________________________

ADD/ADHD: When was your child diagnosed? ___________
Is your child under medical care at this time for this condition?
Yes No
Medication taken at home:____________________________
Medication needed during the school day___________________
Allergy(s): ____Seasonal Allergies ____Insect Allergy
____Food Allergy_________________________________________
____Medicine Allergy______________________________________
Symptoms of Reaction:_____________________________________
Medications taken for this condition at home and/or at school:______

__________________________________________________
Severe enough to have an Epi-Pen/Twinject at home or school?
Yes No If yes, please contact the school nurse.
Asthma: When was your child diagnosed? ______________
Is your child under medical care at this time for asthma? Yes No
Medications taken for asthma:________________________________
________________________________________________________
Medications needed during the school day? Yes No
How often does your child use the rescue inhaler? ____________
Does your child use a nebulizer? ________________________
Blood Disorders: ____Sickle Cell Anemia ____Sickle Cell Trait
_____Clotting Disorder (such as hemophilia) ____Other:_______

__________________________________________________
Diabetes: _____Type 1 ____Type 2
Medical information will need to be on file from the physician
and parent. Please contact the school nurse.

Ears, Eyes, Nose: ____Frequent ear infections
____Hearing Loss R /L Does your child wear a hearing aide? Yes No
____Frequent Nosebleeds caused by:____________________________
____Vision Loss that cannot be corrected with glasses/contacts: R / L
Emotional Issues: ___Depression ___OCD ___Bipolar
___School Phobia ____Other:_____________________
Is your child under medical care at this time for this condition?
Yes No
Medications taken for this condition? __________________________________
Heart Condition: ___Long Q/T syndrome
____Irregular Heart Rate ____ High Blood Pressure
____Heart Defect, type: ____________Repaired? Yes No
Medications taken for this condition:_______________________________
Muscle, Bone, Joint Disorders: ____Arthritis ____Scoliosis
____Other:__________________________________________

Are there any P.E. restrictions for this condition? Yes No
Medications taken for this condition:_____________________
Neurological: ___Migraines ____Autism Spectrum Disorder
____Seizures, type________________Date of last sz? _______________
____Cerebral Palsy ___Spina Bifida ____Other___________________
Medications taken for this condition:__________________________________
Respiratory other than Asthma:
____Cystic Fibrosis ____Other__________________________________
Medications taken for this condition:_______________________________
Other health conditions:_______________________________________
____________________________________________________________
Special procedures: (tube feeing, catheterization, etc._________________
_________________________________________________

In order to determine services available to your child, does he/she have: Insurance_____ CHIPS_____ MEDICAID_____?

Medications must be kept in the school clinic
NO NOTE – NO MEDICATION – NO EXCEPTION

In case of an emergency, I authorize the school to initiate emergency care.
Release:

I hereby grant permission for my child’s physician to report his/her findings to authorized personnel of the C-FBISD.
I agree to notify the school of any changes to information listed above.
I hereby grant permission for information on my child’s health problem(s) to be shared with authorized personnel of C-FBISD.

_________________________________________________
(Parent/guardian signature)
Rev. 4/2011

Checked by staff:____________________

Date__________________

Sign up to vote on this title
UsefulNot useful