K-12 Student Health Questionnaire

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 NameMiddle NameLast Name
Sex*
Birthdate*

MonthDayYear
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

AsthmaReactive AirwayOther
Orthopedic

Broken BonesOrthopedic BracesOther
Heart Problems

Heart MurmurHeart SurgeryOther
List your child's FOOD allergies:
Gland Problems

DiabetesThyroidOther
Neurological Problems

Frequent HeadachesDizziness, Fainting, SeizureADD/ADHDOther
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/UlcerBowel ProblemsSpecial Diet at SchoolOther
Doctor Ordered Special Needs

Glasses/ContactsHearing AidsLimited P.E.Liberal Bathroom PrivilegesBraces/OrthoSeat Close to InstructionOther
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*

YesNo
Emergency Information
Mother's Name

First NameLast Name
Mom's Home Phone

Area CodePhone Number
Mom's Work Phone

Area CodePhone Number
Mom's Mobile Phone

Area CodePhone Number
Father's Name

First NameLast Name
Dad's Home Phone

Area CodePhone Number
Dad's Work Phone

Area CodePhone Number
Dad's Mobile Phone

Area CodePhone Number
Physician's Name*

First NameLast Name
Physician Phone*

Area CodePhone Number
Preferred Hospital*

Iowa Lutheran HospitalMercy Medical Center - DowntownBlank Children's Hospital/Iowa Methodist Medical CenterMercy Medical Center - West LakesMethodist West HospitalOther
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*

MotherFatherGuardian
Today's Date*

MonthDayYear
After you click the SUBMIT button, you will have an opportunity to complete the form for additional students.
Should be Empty: