Student Health Screening Form printable pdf download

Student Health Screening Form

Arlington School –

115 Mill Street, MS 111, Belmont, MA 02478 – (617) 855-2124

Student Health Screening Form

Student Name

DOB

In combination with the most recent record of your child’s Physical Exam, Immunization Records and

Dental Exam, please complete the following checklist and supply all documentation to Arlington

School’s Nurses Office upon enrollment or at the beginning of each school year.

Has your child had a Physical Exam in the past year?

Doctor’s Name

Exam Date

Has your child had a Dental Exam in the past year?

Dentist’s Name

Exam Date

Does your child see an Orthodontist?

Has your child ever had an allergic reaction? Explain:

Has your child ever had an allergic reaction to medication?: Explain:

Does your child have a chronic or ongoing illness?: Explain:

Has your child ever had surgery?: Explain:

Does your child have any physical limitations that may require program modifications and/

/or restrictions? Explain:

Has your child ever taken any supplements or vitamins to help gain or lose weight to

improve performance?: Explain:

Has your child ever experienced a seizure or convulsions?: Explain:

Has your child ever had a head injury or concussion: Explain:

Has your child ever been knocked out, lost consciousness, or lost his/her memory?:

Explain:

M2.01

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FORM

Last update: Aug-14

Student Health Screening Form