|
|
|
School ___________________ Grade _______________ SCHOOL HEALTH RECORD INFORMATION FROM PARENT I. Child's name ___________________ Sex ____ Birth date _____________ Address ____________________________ Phone ______________ Father's Name ____________________________ Work Phone ___________ Place of Employment ____________________________________________ Child's Physician _____________________________ Phone ______________ II. Disease and Illness History (give dates where possible) Communicable Diseases ____________________________________________ Frequent: Sore throats _____ Ear Infections _____ Headaches _____ Convulsions _____ Rheumatic Fever _____ Diabetes ______ Eczema, Hay Fever, Asthma _______ Nervous Symptoms _________ Allergies ________________________________________________________ Injuries (type) ________________________________________ Operations (specify) ____________________________________ Hospitalizations (reasons) _____________________________________________ _________________________________________________________________ Other illness (pains, etc.) ______________________________________________ _________________________________________________________________ III. Emotional and Behavior History (note special problems and age of occurrence) _________________________________________________________________ _________________________________________________________________ IV. Medications ____________________________________________________ DATE _________________ SIGNATURE OF PARENT _________________________ |
|
HOME | ABOUT US | LINKS | STUDENT PAGE | WEATHER | PHOTO GALLERY | CONTACT US | FIND US |