East Montpelier Elementary School - Annual Health Questionnaire
School Year 2009-2010
This form will be kept in the Student’s Health Record and used as a reference throughout the year. All information is confidential and
will be shared only with staff that needs to know. Please answer completely. For the sake of confidentiality, you may choose to mail
this questionnaire to the school or place it in an envelope addressed to Elizabeth Wirth, School Nurse.
School Year 2009-2010
This form will be kept in the Student’s Health Record and used as a reference throughout the year. All information is confidential and
will be shared only with staff that needs to know. Please answer completely. For the sake of confidentiality, you may choose to mail
this questionnaire to the school or place it in an envelope addressed to Elizabeth Wirth, School Nurse.
