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Karen G. SnyderPrincipal

715 Sanders StreetAuburn, Alabama 36830

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Rebekah H. Hunter KlmBerly H. CoreCounselor Apistant Principal

, Phone:334-887-494AFax: 334-887-4772

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Dear CWES Parent/Guardian,

To continue the registration process, the attached form is required by the State of Alabama to be on file

for all public school students. ln order to properly address medical concerns at school, it is important

that this form is complete with accurate and up to date information. Please contact the school if you

have any questions regarding the form.

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ALABAMA STATE DEPARTMENT OF EDUCATION

HEALTH ASSESSMENT RECORD

School Year: Jors -3"olb

To Parent or Guardian:The purpose of this form is to provide the school nurse with additional information regarding your child's health needs. The school nurse may contact you forfurther information. The information requested is essential for the school nurse to meet the health needs of your child,

1ruffi*ffi , dtx*Tih*tt :ffi ffi ,$f d.uc, 6f Return to the School Nurse)

Name of Student (Last, First, Middle)

Home Telephone Number: Teacheri Homeroom

Name of ParenUGuardian (Last, First Middle) Work Phone Number:

Transportation

E Bus Rider Bus Number: E 9ar Rider n Special Needs Bus I After School

Place your child receives health care:

Physician's Name: -

Place your child receives dental care:

Address: Address:

Phone: Phone:

I Community Health Center

I Health Department

n HospitalClinic

I No Regular Place

D Private Doctor /HMO

Preferred Hospital:

Your child's lnsurance lnformation:

N ALL KIDS

tr Medicaid

! No lnsurance

tr Other_

I Private lnsurance

Dentisfs Name:

tr Community Health Center

il Health Department

tr Hospital Clinic

[1 No Regular Place

fl Private Dentist /HMO

Address (Street)

Additional Phone Number:

Part l- Health Information

Part l l - Medical Medical /Procedures uired at School

Medications and Procedures at School require a PrescriberlParent Authorization Form (one for each medication orprocedure) Please see your school nurse.

n Catheter n Gastric Tube n Nebulizer Treatments n Oxygen Supplement n Tracheostomy

n VagalNerve Stimulator (VNS) n Ventilator n Wheelchair n Walker

Page 1

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ALABAMA STATE DEPARTMENT OF EDUCATION

HEALTH ASSESSMENT RECORD

schoor Year: J.O 15 --eQlt"

Part l l l - Medical Hn YESn NO KNOWN HEALTH PROBLEMS

lf NO, go directly to the bottom of the page and provide parent/guardian signaturelf YES, and diagnosed by a physician, answer each question below.

n Y E S n N On YESn NO

Attention peficit Disorder (ADD)Attention Deficit Hyperactivity Disorder (ADHD)Reouires medication n At school u At Home

tr YES n NO Allergies:n Foodn Insects

n Hives/rash n Medications

n Environmentaln Medications

n Breathing difficulty n EPi-Pen

n Other;n Y E S n N O Asthma r Uses an inhaler at school n Uses an inhaler at home

r Y E S n N O Blood/Bleeding Problems: aHemophil ia,n Requires medication P/ease explain:

Frequent Nose Bleeds: P/ease explain

nVon Willebrand's, aOther

n YESn N0n YESg NO Cancer/Leukemia: P/ease explainn YESn NO Cerebral Palsv: Please explainn Y E S I N O Cvstic Fibrosis: P/ease exnlainn Y E S o N O Dental Problems: Please explain:n Y E S a N O Diabetes n Type 1 Diabetes n Monitors Blood Sugars at school

n Managed with diet

n Reouires Insulin at schooln Insul in pumpa Glucagon ordern Oral medicationn Type 2 Diabetes

r Y E S a N O Emotional/Behavioral/Psvcholooical : Please expl ain :n Y E S n N O Gastrointestinal/Stomach Problems: P/ease explain:n Y E S n N O Genetic / Rare Disorders: P/ease explain:a Y E S n N O Headaches: Please explain:a Y E S n N O Hearing Problems: n Right Ear n Left Ear a Both ears n Hearing loss a Hearing aid

n Tubes n Cochlear lmplantn YESn NO Heart Condition: n Activity restrictions: n Medications taken at home:

Please explain:n Y E S a N O Hvoertension (Hiqh Blood Pressure): P/ease explain:n Y E S n N O Juvenile Arthritis/BoneJoint Problems: P/ease ex plain :a Y E S I N O Kidnev/ Bladder/ Urinarv Problems: Please explain:n YESn NO Scoliosis: a No Treatment n Wears Brace n Surgery n Family Historyn YESn NO $eizures/Convulsions: Type of seizure:

Medications: nDiastat aKlonopinPIease explain:

n Versed a Medication taken at home n Other

n Y E S n N O Sickle Cell: n Anemia o Traitn YESn NO Shunt: s VP shunt P/ease explain:n YESn NO Soina Bifida:n Y E S r N O Special Diet: P/ease explain:n YESg NO Vision Problems: n Wears olasses a Wears contacts n Othern Y E S o N O Other Medical Conditions: P/ease include ̂nv medications taken at home only.

$ignature of parent{e} or guadian:i

of school nurse:Page 2

Rev 5-2014