Editing previous response:

Please fix the highlighted areas below before submitting.

2025-26 Student Health Questionnaire

Please complete this required form for each of your children attending SJCS for 2025-26 school year. Required fields marked are with an asterisk *

Last Name of Student*

Answer required for "Last Name of Student"

First Name of Student*

Answer required for "First Name of Student"

Date of Birth*

Answer required for "Date of Birth"

Gender*

Answer required for "Gender"

Female

Male

Grade Entering for 2024-2025 year*

Answer required for "Grade Entering for 2024-2025 year"

Health Requirements and Medical Upload

Dental forms are not due to the state until May 15th, however dental forms are good for 18 months, so if you have a dental form from any visit occuring between Jan 15th 2025 onwards please upload it now. Please make sure to upload the forms to the their correctly desigated places. The health requirements for each grade are as follows:

HEALTH REQUIREMENTS BY GRADE

Preschool- Only if entering SJCS Preschool for the first time.	Physical
Kindergarten	Physical Eye, Dental
Second Grade	Dental
Fifth- Eighth Grade	Sports Physical if participating in a school sponsored athletic program. IHSA Form
Sixth Grade	Physical, Dental
New Students (enrolling in an Illinois school for the first time)	Physical,Eye, Dental (only if entering K, 2, 6th)

Preschool Physical Form

Answer required for "Preschool Physical Form"

Choose a file or drag it here.

Kindergarten Forms (Physical, Dental, Eye)

Answer required for "Kindergarten Forms (Physical, Dental, Eye)"

Choose a file or drag it here.

2nd grade Dental

Answer required for "2nd grade Dental "

Choose a file or drag it here.

5th-8th grade Sport's Physical

Answer required for "5th-8th grade Sport's Physical"

Choose a file or drag it here.

6th grade Forms (Physical, Dental)

Answer required for "6th grade Forms (Physical, Dental)"

Choose a file or drag it here.

New Students (Physical, Dental, Eye)

Answer required for "New Students (Physical, Dental, Eye)"

Choose a file or drag it here.

Does your child have any type of hearing or vision impairment?*

Answer required for "Does your child have any type of hearing or vision impairment?"

yes

If yes, please explain.

Answer required for "If yes, please explain."

If you checked "yes" above, please check all that apply

Answer required for "If you checked \"yes\" above, please check all that apply"

Glasses all the time

Glasses for distance

Glasses for reading only

Glasses for sports

None

Other:

If applicable, date of last eye exam?

Answer required for "If applicable, date of last eye exam?"

Life Threatning Medical Conditions

Students with life-threatening medical conditions, where the condition would "put the child in danger during the school day", should have a nursing action plan and medication authorization form and physician's order (all listed below) in place before the first day of the new school year. These plans are required to be updated yearly, and includes individuals who are "self-caring / self-administering".

Does your child have any Life Threatening Allergic Conditions?*

Please select all that apply

Answer required for "Does your child have any Life Threatening Allergic Conditions?"

Severe allergic reaction to bee stings, other insects

Severe reaction to any foods (nuts, sesame,...)

Severe Asthma: regularly takes medication for asthmatic condition or hospitalized within the last 5 years for asthmatic condition.

Diabetes

Seizure disorder that requires emergency medication

None/Other

If you checked any of the above boxes, please use this space to provide any important information that you feel the school nurse should be aware of. This information is only seen by the school nurse and will remain confidential. If "none" type N/A

Answer required for "If you checked any of the above boxes, please use this space to provide any important information that you feel the school nurse should be aware of. This information is only seen by the school nurse and will remain confidential. If \"none\" type N/A"

Has the child's physician prescribed an Epi-Pen or any other medicine for a severe, life threatening allergy?*

If yes, it is strongly advised that he/she keeps a supply in the nurse's office; it is required for interscholastic sports (5-8), with a physician's order specifying "self administer". See school medication policy for more info.

Answer required for "Has the child's physician prescribed an Epi-Pen or any other medicine for a severe, life threatening allergy?"

yes

Has your child been diagnosed by a licensed physician with any of the following health conditions?*

Check all that apply

Answer required for "Has your child been diagnosed by a licensed physician with any of the following health conditions?"

ADD/ADHD without medical prescription

ADD/ADHD with medical prescription

Allergies (environmental or seasonal)

Asthma/Reactive Airway with nebulizer or inhaler treatment

Asthma/Reactive Airway without nebulizer or inhaler

Autism

Bowel or digestive

Diabetes

Bowel or digestive issues

Kidney or urinary

Migraine headaches

Orthopedic

Skin

Surgery (within the last year)

Seizure Disorder

Other

None

Medical Action Plan (asthma, allergy...)

Answer required for "Medical Action Plan (asthma, allergy...)"

Choose a file or drag it here.

Medication Authorization and Physician Order

Answer required for "Medication Authorization and Physician Order"

Choose a file or drag it here.

Daily Medications and School Medication Policy

If your child has a medical condition that requires medication (prescription or over-the-counter) to be administered during the school day, a written physician's order is required. No medication may be carried in school by a student; again, this applies to prescription or over-the-counter medications.

The only exceptions are for those students with asthma inhalers and EpiPens whose order specifies that they may "self administer" their medication. All medication must be delivered to the school nurse's office in the original container or pharmacy bottle by the parent/guardian with the physician's original order and written parental permission.

Archdiocese of Chicago Medication Administration Form

List any prescription, over the counter or herbal medications that your child takes regularly

This information will be shared medical personnel should in the event of an emergency.

Answer required for "List any prescription, over the counter or herbal medications that your child takes regularly"

Will your child require to take medication(s) during the school day?*

Answer required for "Will your child require to take medication(s) during the school day?"

yes

If yes, please list the medication name, dose, time to be given and reason for taking. The Archdiocese Medication Authorization Form is required for ANY medication to be administered during the school day, even self-administered medications.*

Answer required for "If yes, please list the medication name, dose, time to be given and reason for taking. The Archdiocese Medication Authorization Form is required for ANY medication to be administered during the school day, even self-administered medications."

Medication Authorization and Physician Order

Answer required for "Medication Authorization and Physician Order "

Choose a file or drag it here.

Is your child allergic to any of the following medications?*

Answer required for "Is your child allergic to any of the following medications?"

Penicillin

Amoxicillin

Sulfa

Aspirin

Nonsteroidal anti-inflammatory (Ibuprofen, naproxen)

Tylenol

None/Other

Please list "other" medication(s) here and describe the reaction that occurs if taken.

Answer required for "Please list \"other\" medication(s) here and describe the reaction that occurs if taken. "

Is there any other pertinent medical information that you would like the school nurse to be aware of that might require a modification in your child's school day? Please explain, or type N/A if there is nothing to report.*

* Any condition that would prevent full participation in educational programs (including physical education) requires physician documentation before modifications can be considered.

Answer required for "Is there any other pertinent medical information that you would like the school nurse to be aware of that might require a modification in your child's school day? Please explain, or type N/A if there is nothing to report."

I certify that the information I have provided in this form is true, accurate and complete to the best of my knowledge. I acknowledge that if the health of my child changes at anytime during the school year, I will inform the school nurse.*

Type the name of the person completing this form below

Answer required for "I certify that the information I have provided in this form is true, accurate and complete to the best of my knowledge. I acknowledge that if the health of my child changes at anytime during the school year, I will inform the school nurse."

Confirmation Email

Answer required for "Confirmation Email"

Submitting form...

Protected by reCAPTCHA - Privacy - Terms

Please verify you are not a robot:

Please fix errors above