Student Health History CHS

Student Health History CHS

Covington City Public Schools

2021 – 2022 Student Health History Form
(Please complete entire form and submit as soon as possible.) 

Student Health History Information

Please answer all questions. If any of your information changes during the year, please call the school office or send an email to the school to update information. Thank you.

Name:(Last)  (First)  (Ml)  SexMale  Female

Grade:  Birthdate:  Homeroom Teacher:  

Parent/Guardian (Call 1st) Relationship to student:  

Home #  Work #  Cell # 

Parent/Guardian (Call 2nd):  Relationship to student:  

Home #  Work #  Cell # 

Emergency contact names/numbers if parent listed above cannot be reached:
1. Name:  Relationship:  

  Home #  Work #  Cell #  

2. Name:  Relationship:  

  Home #  Work #  Cell # 

Physician:   Dentist: 

Your child has the following health insurance (Please select all that apply) Private Medicaid FAMIS None

Please select all that apply to student: 

Allergies/Hayfever (list below) Bleeding/Clotting Disorder Head Injury -Concussion Orthopedic/Bone 
Bee Sting/Insect Allergy
(list below)
Cerebral Palsy Headaches Medication Allergies - Reaction
(list below) 
ADHD Chickenpox Hearing Loss Psychological - Psychiatric Treatment 
Anemia (include Sickle Cell) Cystic Fibrosis Heart Condition - Murmur Scoliosis 
Arthritis Diabetes Hypertension Seizures 
Asthma Food Allergy (list below) Lead Exposure Skin Disorders 
Bladder/Kidney Disease Gastro-intestinal Mononucleosis Vision Loss/Correction 

Please give details/dates of all conditions marked above and other health conditions not listed. 

Is your child taking medication (Prescription or Over-the-Counter)? Yes  No  If Yes, complete the following: 

Name:   Dosage:   Reason for use: 

Name:   Dosage:   Reason for use: 

If more than two, please list below: 



*I give permission for my child to have the following medications if the nurse/school personnel feel it is necessary. I understand and accept that the Alleghany County/Covington School Boards, its employees, agents or designees are not responsible for any effects of the medication administered.

Tylenol: Yes  No   Benadryl: Yes  No   Cough Drops: Yes  No

*I give permission for the nurse to share information with administration/faculty regarding health problems that may require emergency intervention. Yes  No

*I give permission for my child to be transported to the hospital in the event of an emergency.
Yes  No

*I authorize my child's health care provider and designated provider of health care/school official to discuss my child's health concerns and/or exchange information You may withdraw your authorization at any time by contacting your child's school. Yes  No

Please see school handbook in regard to medication at school and on the bus.


Parent/Guardian:   Date: 



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