Skyline Schools

Health Survey


Section 1 of 3


Date      Grade

Last Name    First Name    Middle Initial     Male   Female


Birth Place

Family Doctor  Phone

Family Dentist  Phone


Family History

List any significant handicap or illness in the empty box next to each age.

FatherŐs Age    

MotherŐs Age    

Brother/Sister Name   Birthday    

Brother/Sister Name   Birthday    

Brother/Sister Name   Birthday    

Brother/Sister Name   Birthday    

Brother/Sister Name   Birthday    

Section 2 of 3


Past or present health status of pupil.

Check and describe any of the conditions that apply. Descriptions are only necessary for checked items.

 Childhood diseases



 Convulsive disorders

 Heart condition

 Allergies (drug, food, insect, etc.)






 Frequent colds or sore throat

 Earaches or draining ears

 Vision problems

 Dental problems

 Orthopedic condition

 Skin problems

 Behavior/personality problems

List other serious illnesses here


Is the student taking any medications at this time.   Yes   No

If yes, list the medication here.

Reason for medication.


List any limitations or restrictions in physical education.

*A physicianŐs statement regarding anything listed in the above box is required.


Hearing and speech

            Hearing problem    Yes   No

Wears hearing aid   Yes   No

Has seen specialists   Yes   No   Describe treatment  

Family history of hearing loss   Yes   No


Speech History

            Speech problem    Yes   No

Voice problem   Yes   No

Therapy   Yes   No



            Family history of vision problems

            Does child wear glasses    Yes   No      Year starting wearing glasses  

Specialist name  




Section 3 of 3




I give permission to the school authorities present during any emergency or accident involving this student to obtain the services of a physician and/or to transport the student to the nearest hospital (or if possible, the noted hospital of choice listed on this form).  I also give permission to the physician/hospital to treat the student in my absence.


Health files are kept confidential; however I understand and give my permission for the school nurse/administration to determine when appropriate portions of my childŐs health file may be shared with other school district staff members that are providing a service to my child.


I give consent for the immunization information in my childŐs health file to be released to the Kansas Immunization Program and other health facilities as needed for the purpose of assessment and reporting.  There are a number of diseases that are required by law to be reported.


During the school year I may be contacted by the school nurse to discuss my childŐs health or health plan needs. I give consent for school vision and hearing screenings.


By signing below, I affirm that the information given on this registration form is correct to the best of my knowledge and that the school will be notified of any new changes in my childŐs health conditions or medications.  I understand that this authorization will expire when the student is no longer enrolled at Skyline and that I may revoke this authorization in writing at any time.


________________________________                                _____________________

Parent/Guardian Signature                                                      Date



End of Form


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