State of Connecticut Department of Education
Health Assessment Record
To Parent or Guardian:
In order to provide the best educational experience, school personnel must
understand your child’s health needs. This form requests information from you
which will also be helpful to the health care provider when he or she
completes the medical evaluation.
To be completed by parent/guardian. Please answer these health history questions about your child before the physical examination.
All medications taken in school require a separate Medication Authorization Form signed by a health care provider and parent/guardian
By signing below, I give permission for release and exchange of information on this form between the school nurse and health care provider for confidential use in meetings my child's health and educational needs in school.
Please click SUBMIT when complete