Name: ____________________________________ Gender: _________ Grade: ________
Mother's Name: _____________________________ Father's Name: _______________________
Family Doctor: ______________________________ Phone: _____________________________
Family Dentist: ______________________________ Phone: _____________________________
Primary language spoken in the home: ________________________________________________
Health History - mark with an "X" if applicable and describe below under "Comments" if necessary
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Comments (please use additional sheet if necessary):
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Has your child been seen by any of the following Health Care Professionals?
| Specialty | Name of Specialist | Date Seen | Reason |
| Allergist | |||
| Eye, Ear, Nose, Throat | |||
| Orthopedist | |||
| Psychiatrist | |||
| Psychologist | |||
| Social Worker | |||
| Other |
Does your child have any allergies (medicines, foods, insects, environmental, other)? What happens when your child has an allergic reaction?
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Does your child have any chronic illnesses or physical limitations?
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Is your child on any medication? Please name the medicine.
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Is there any other information that the school should know in order to safeguard your child's health?
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Additional Comments:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Parent's Name: ________________________________________________________________
Parent's Signature: _______________________________________Date: _________________