School Health Records Survey
Please complete this survey to help us understand and support student health at school. Do not provide sensitive or confidential information.
Student Full Name
*
First Name
Last Name
Grade Level
*
Please Select
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
Other
Does the student have any known allergies?
*
No
Yes, food allergies
Yes, environmental allergies
Yes, medication allergies
Other
Has the student received all recommended childhood immunizations?
*
Yes
No
Unsure
How would you rate the student's general physical health?
*
1
2
3
4
5
How often does the student participate in physical activity (e.g., sports, PE, play)?
*
Daily
Several times a week
Once a week
Rarely
Does the student have any dietary restrictions?
*
No
Vegetarian
Vegan
Gluten-free
Other
Has the student had a vision or hearing screening in the past year?
*
Yes, both vision and hearing
Yes, vision only
Yes, hearing only
No
Unsure
In the past month, how many days has the student missed school due to illness?
*
Please Select
0 days
1-2 days
3-5 days
More than 5 days
Please share any additional health-related information or concerns (optional)
Submit Survey
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