Registration Form

School Student Health Screening

First Name

Last Name

Student ID

Date of Birth

Gender

Grade Level

School / College Name

Parent/Guardian First Name

Last Name

Parent/Guardian Email

Parent/Guardian Phone

Does your child have any allergies?

Yes

No

If yes, please specify allergies and reactions:

Is your child currently taking any medications?

Yes

No

If yes, please specify medications and dosages:

Does your child have any chronic health conditions (e.g., asthma, diabetes)?

Yes

No

If yes, please specify conditions and management plans:

In the past 24 hours, has your child experienced any of the following symptoms?

Fever (100.4°F or higher)

Cough

Sore Throat

Difficulty Breathing

Loss of Taste or Smell

Headache

Muscle or Body Aches

Fatigue

None of the above

If other symptoms, please specify:

Screening Date

Screening

First Name

Last Name

Emergency Contact Phone

Additional Notes

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