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St. Ann Catholic School SCHOOL HEALTH RECORD Grade ___ 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 _________________________________
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