K-12 Student Health Questionnaire

Please send a copy of this completed form to this E-Mail address:

Student Information
Please complete one form per student

Full Name *

First Name Middle Name Last Name

Sex *

Birthdate *

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Grade Entering *

If your child is on routine medication or has a health condition that may require action by the nurse, you must call the nurse to set up an appointment to discuss your child’s health needs before the student begins attending DMCS.

Breathing Problems

Asthma Reactive Airway

Orthopedic

Broken Bones Orthopedic Braces

Heart Problems

Heart Murmur Heart Surgery

List your child's FOOD allergies:

Gland Problems

Diabetes Thyroid

Neurological Problems

Frequent Headaches Dizziness, Fainting, Seizure ADD/ADHD

I give permission to the school nurse to give my child an age appropriate dose of the following medication when needed. DMCS will dispense up to five (5) total doses per year without a doctor’s order. Cough drops and chapstick will be allowed in class. Individual teachers may refuse the privilege if misused.

Ibuprofen (Advil / Motrin) Acetaminophen (Tylenol)

Eating Problems

Stomach Problems/Ulcer Bowel Problems Special Diet at School

Doctor Ordered Special Needs

Glasses/Contacts Hearing Aids Limited P.E. Liberal Bathroom Privileges Braces/Ortho Seat Close to Instruction

List your child's MEDICINE allergies:

List your child's ENVIRONMENTAL allergies:

List prescribed medications to be given at school:

These must be given to the nurse in their original container.

List any illnesses, operations or accidents your child had in the past year:

List any emotional, social or other conditions that might affect your child’s school performance:

My child has been outside the US during the past year *

Yes No

Emergency Information

Mother's Name

First Name Last Name

Mom's Home Phone

Area Code Phone Number

Mom's Work Phone

Area Code Phone Number

Mom's Mobile Phone

Area Code Phone Number

Father's Name

First Name Last Name

Dad's Home Phone

Area Code Phone Number

Dad's Work Phone

Area Code Phone Number

Dad's Mobile Phone

Area Code Phone Number

Physician's Name *

First Name Last Name

Physician Phone *

Area Code Phone Number

Preferred Hospital *

Iowa Lutheran Hospital Mercy Medical Center - Downtown Blank Children's Hospital/Iowa Methodist Medical Center Mercy Medical Center - West Lakes Methodist West Hospital

Des Moines hospitals require a parent signature to give emergency treatment to minors not accompanied by a parent. Every effort will be made to notify parents or others shown on the form in the event of an emergency. However, this Medical Authorization will allow treatment or care until such time as the parents can be reached.

I give permission to the school nurse to share health and emergency information with school staff on a need to know basis. I give my permission and/or consent to Des Moines Christian School to secure and authorize such emergency medical care and/or treatment as my child (above named) might require while under the supervision of Des Moines Christian School. I also agree to pay all costs and fees contingent on any emergency medical care and/or treatment for my child as secured or authorized under this consent. I agree to this authorization for the time that my child attends Des Moines Christian School and will inform the school as to any change in the name of the medical provider, hospital, or my child’s medical condition. *

I agree

Parent/Guardian Name *

Relationship to Student *

Mother Father Guardian

Today's Date *

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After you click the SUBMIT button, you will have an opportunity to complete the form for additional students.