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Health Services Forms


Health History Form/Historia de Salud (
Required for all new students or if there are any changes to your child's health status.)

Parent Authorization for Release of Health Information 

Referral to Nurse

Forms Required by CA State Law

Report of Health Examination for School Entry 

Oral Health Assessment Form EN and SP

Oral Health Parent Waiver EN and SP

Oral Health Parent Notification Letter EN and SP

On-site Dental Screening Opt-out EN and SP

Forms for Medication at School

Medication Authorization Form (Required for all students who take any medication at school. A new form must be completed every year.)

Forms for Physicians

Physical Education Modification  (Use this form if/when your student has health or physical limitations which may interfere with their participation in PE)

Request for Physician Information (Use this form if/when parents/guardians are asked for additional information from a physician regarding a student health issue or injury)

Allergy/Asthma Forms

Allergy Health Care Plan 

Allergy Questionnaire

Food Allergy Action Plan (FARE)

Asthma Questionnaire

Bee and Insect Sting Questionnaire

Diabetes Forms

Diabetes Health Care Plan Request

Diabetes Questionnaire 2022

Type 1 Diabetes Information Sheet

Seizure Forms

Seizure Questionnaire

Seizure Emergency Action Plan

Epilepsy Foundation Seizure Action Plan