SWP Intake Form (Student Emergency Contact & Health Information)

1. Contact Information

Student Name

Preferred Name

Date of Birth This question requires a valid date format of MM/DD/YYYY.

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Student Phone Number

Student Grade

Student Gender

Address

City

State

Zip

County of Residence

Parent/Guardian Name

Phone

Email This question requires a valid email address.

Relationship to Student

Legal Custody

Parent/Guardian Name

Phone

Email This question requires a valid email address.

Relationship to Student

Legal Custody

Emergency Contact

Phone

Relationship to Student

2. Student Physician

Name

Physician Phone Number

3. Insurance

No Health Insurance
Request application for MI/Medicaid

4. Preferred Hospital

5. Race (Check all that apply)

White
Black/African American
Asian

Native Hawaiian/Pacific Islander
American Indian/Alaskan Native
Not Listed

6. Ethnicity

Hispanic/Latino
Not Hispanic/Latino
Arabic/Chaldean

7. Allergies

Allergies?

Require emergency epi pen?

List allergies

8. Asthma

Asthma?

Require emergency inhaler?

List triggers

9. Seizures

Seizures?

Require emergency medication?

Date of last seizure This question requires a valid date format of MM/DD/YYYY.

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10. Diabetes

Diabetes?

CGM?

Pump?

Diagnosis Date This question requires a valid date format of MM/DD/YYYY.

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11. Any additional information about anything listed above or other medical or mental health concerns, past surgeries, hospitalizations, or major injuries?

12. List any medications taken regularly at home.

13. Over-the-counter medications

SWP Intake Form (Student Emergency Contact & Health Information)

Student Emergency Contact and Health Information