SACRED HEART SCHOOL                                                
2009-2010 HEALTH ASSESSMENT REPORT AND PERMIT                         
                       
                                             
STUDENT NAME:                SEX:        M        F        GRADE:        
HOME ADDRESS:                                                
                                             
      ALLERGIES        SEASONAL                CHRONIC                MEDICATION
     Food                                        
     Medicine                                        
     Environment                                        

     BONE OR JOINT DISEASE AND/OR INJURY (Please Explain):                                        


     DIABETES                                        
     Initial Diagnosis Date:                                        
     Required Medication(s):                                        
     Degree of Control:                                        
     Insulin Reactions:                                        
     HYPOGLYCEMIA (LOW BLOOD SUGAR)                                        
     Special Diet:                                        
                                             

     DENTAL (Orthodontist)        Braces _______  Dentures  _______                                

     EAR INFECTIONS        Tubes Inserted_______Tubes Removed _______                            
    

     HEARING LOSS        Hearing Aid:                                
     Degree of Impairment:                                        

     VISION        Glasses                        Full-time        
             Contact Lenses                        Full-time        

     HIGH BLOOD PRESSURE (Please Explain):                                        
     Medications:                                        
                                             
     HYPERACTIVITY (Please Explain):                                        
     Medications:                                        

     HYPERVENTILATION (Please Explain):                                        
                                             
     THROAT INFECTIONS (Chronic)                                        
     HEAD INJURY (Please Explain)                                        
     HEART DISEASE (Please Explain)                                        
     FAINTING (Please Explain)                                        
     KIDNEY/BLADDER (Chronic)                                        
     HEART DISEASE                                        
     CONVULSIVE DISORDERS                                        
     Grand Mal                Medication:                        
     Petit Mal                Medication:                        
     Fever Convulsions                Date of Last Episode:                        

     CHRONIC DISORDER NOT MENTIONED                                        


     OPERATIONS NOT PREVIOUSLY MENTIONED                                        


     NOTE ANY TYPE OF HEALTH APPLIANCE CHILD MAY USE                                        
                                             

     LIST ANY CURRENT MEDICAL TREATMENT CHILD IS RECEIVING                                     
   


     EMOTIONAL ISSUES (Please Explain)                                


Are there any factors in the family that might affect your child's school experience or assist us
in serving your child?                                        
(Please Explain):                                        

At the present time, do you have any questions and/or concerns you would like to discuss
with:                                        
     Principal                                
     Teacher                        Grade:        
     Counselor                                

MY CHILD HAS HAD THE FOLLOWING COMMUNICABLE DISEASES:                                       
 
     Chicken Pox                Date:                
     Measles                Date:                
     Red Measles                Date:                
     Meningitis                Date:                        
     Scarlet Fever                Date:                        
     Infectious Mono                Date:                        
     5th's Disease                Date:                        
     Other                Date:                        
OFFICIAL IMMUNIZATION RECORDS (CIRCLE TOTAL DOSES RECEIVED SINCE BIRTH):      
                                          
0   1         Measles                                               Date of Last Dosage:                                      
  
0   1        Mumps                                                Date of Last Dosage:                                        
0   1        Rubella                                                Date of Last Dosage:                                       
 
0   1   2   3   4   5        Oral Polio                                            Date of Last Dosage:                   
                     
0   1   2   3   4   5        Diphtheria/Tetnus                                 Date of Last Dosage:                  
                      
     {DPT or TD Boosters are due every 10 years                                         
     and are available from the Health Department}                                        

I AUTHORIZE SCHOOL PERSONNEL TO OBTAIN EMERGENCY MEDICAL CARE FOR MY
CHILD IN THE                                                
EVENT I CANNOT BE REACHED.  IF TRANSPORTATION BY AMBULANCE IS REQUIRED,
THIS SERVICE MAY                                                
BE OBTAINED.  IF MY DOCTOR IS NOT AVAILABLE, ANOTHER DOCTOR (ON CALL) MAY
BE CONSULTED.                                                

If necessary, the Principal may give non-aspirin (Tylenol) to my child:                Yes                
No                

                                             
PARENT / GUARDIAN'S SIGNATURE                        DATE