Regarding your child’s health inspection, we request that you fill out this form with your child’s information and return it as soon as possible to the school nurse. The information supplied with the form is confidential, and it will not be disclosed to third parties by the health care department without your consent.
	
1. Family	Last and first names of the child
     	Personal identity number
     	
	Home address 
     	
	Native language of the child
     	Language spoken at home
     	
	Name of the guardian 
     	Phone number
     	
	Name of the guardian 
     	Phone number
     	
	Persons living in the same household as the child
     	
2. School attendance and friendships	How is your child doing at school?
     	
	How much time per day do they spend on completing homework?
     	
	Does your child require assistance with homework?
     	
	Does your child receive special education / other support at school?
     	
	How much has your child been absent from school?
     	
	Has your child experienced bullying at school?
     	Does your child bully others?
     	
3. Health routines	Child’s eating habits, special diets, etc.
     	Does your family eat together?
     	
	Child’s sleeping duration
     	Child’s daily screen time (TV, computer, video game consoles, etc.)
     	
	How does your family spend time together?
     	
	How does your child spend their free time?
     	
	Are there smokers in your family?
     	
	Is alcohol or other intoxicants used in your family?
     	
4. Health	Do you think that your child is healthy?
     	
	Does your child experience recurring headaches, stomach pain, sleeping difficulties, allergic reactions?
     	
	Does your child suffer from any long term diseases? Who is responsible for their treatment?
     	
	Medication needs, name of medication
     	
	Has your child received any rehabilitation? Such as speech therapy, occupational therapy, physical therapy, etc.
     	
5. Puberty and development	Have you had discussions within the family about puberty-related matters? (Mood, physical changes, dating, etc.)
     	
	Have you agreed upon curfew times with your child?
     	Do you know where your child spends their free time?
     	
6. Current situation of the pupil and the family	What is your child good at?
     	
	What are the strengths of your family?
     	
	What do you feel you have been successful in?
     	
	Sometimes there are changes that the child and the family must go through, and those changes may bear significance to the successfulness of your child’s school career. Do you have any matters related to your family’s health and well-being you wish to discuss?
     	
7. Signature	Place and time

     	Guardian’s signature

     	
8. School nurse	Name and phone number

     	

Thank you!