Guidelines for Policy 311

St. Ann Catholic School

3064 Pleasant Ave

Hamilton, OH 45015

(513) 863-0604

Fax: (513) 863-2017

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 _________________________