Health Form - bsb.edu.az

School Entrance Health Form

(To be completed by Parent or Guardian and discussed with nurse if appropriate) ( Please send in separate envelope marked Confidential-Nurse)(In Answering The Following Questions, Please Circle YES or NO)

Name of Student:

Date of Birth

Grade/Year:

Age:

Has your child had a physical examination in the last year?

YES NO

Has your child ever had an allergic reaction ( to food, medicine, insect bites or any other cause)?

YES NO

Does your child have asthma?

YES NO

Is your child susceptible to frequent colds and throat infections?

YES NO

Does your child have a persistent cough?

YES NO

Has your child had any ear trouble or problems with hearing?

YES NO

Has your child any eye trouble or problems with seeing?

YES NO

Does your child wear glasses or contact lenses? Date of last exam

YES NO

Does your child see a dentist and/or orthodontist on a regular basis?

YES NO

Does your child have convulsions or seizures?

YES NO

Does your child have a heart condition?

YES NO

Has your child had any marked changes in weight recently or do you consider him/her to have any problems with eating or weight?

YES NO

Does your child frequently complain of abdominal pain?

YES NO

Does your child have frequent headaches?

YES NO

Has your child had a stool or urine test in the last year?

YES NO

If your child is over 5 years old, does s/he frequently wet the bed?

YES NO

Has there been any recent family history of chronic or infectious illness (eg. heart disease, diabetes, mental illness, tuberculosis, hepatitis or other infectious disease).

YES NO

Does your child have any emotional or behavioural difficulties which may affect his school day?

YES NO

Is your child taking any medications, tablets or vitamins now?

YES NO

Does your child have any present physical limitations tha affect school activities?

YES NO

Does your child require any special procedures or medication during the school day?

YES NO

There are health concerns I would like to address (please list/make appt. with nurse)

YES NO

CALLS, DISCUSSIONS, CONCERNS AND QUESTIONS FROM THE FAMILY TO THE NURSE RELATING TO THE STUDENT’S HEALTH ARE WELCOME AND ENCOURAGED

Email

[email protected]

Phone number

(99412) 465-80-86
(99412) 447-40-81
10 325 00 12

Address

Koroglu Rahimov str. 13, Baku, AZ1072

Email

[email protected]

Phone number

Address

Koroglu Rahimov str. 13, Baku, AZ1072, Odlar Yurdu University