WLES - Health Assessment Record

To Parent or Guardian:
The purpose of this form is to provide the school nurse with additional information regarding your child's health needs. The school nurse may contact you for further information. The information requested is essential for the school nurse to meet the health needs of your child.
This information will be kept confidential.

1Basic Information > 2Health Information > 3MH Prescreener > 4Medical History > 5Signature
Student's Name Student's Name * First Middle Last
Birth Date Birth Date * / MM / DD YYYY
Sex *
School *
Grade *
Address Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Name of Parent/Guardian Name of Parent/Guardian * First Middle Last
Phone number to reach during school hours Phone number to reach during school hours * - ### - ### ####
Name of Second Parent/Guardian Name of Second Parent/Guardian First Middle Last
Phone number to reach during school hours Phone number to reach during school hours - ### - ### ####
Before School Transportation *

Before School Transportation Bus Rider Car Rider Special Needs Bus After School Care Other Other
After School Transportation *

After School Transportation Bus Rider Car Rider Special Needs Bus After School Care Other Other