Student Medical History Form

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First found May 22, 2018

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CHEHALIS SCHOOL DISTRICT STUDENT MEDICAL HISTORY
1. STUDENT INFORMATION:
Student's Name:
Birthdate:
Parent/Guardian:
Parent/Guardian:
Home Phone:
Work Phone:
Doctor/Clinic:
Phone:
Male
Female
Cell Phone:
Dentist/Clinic:
Phone:
The following information is needed to plan an appropriate program for your child, and to handle any
emergencies. You may use the back of this form if you have any additional information. It is vital to your
child’s safety during the school day that if your child has a life-threatening health condition that may
require medical services to be performed at school, you immediately notify your school’s principal or
school nurse. The necessary forms will be provided and a time will be arranged for you to meet with
your child’s school nurse.
2. MEDICAL HISTORY:
(Check all that apply to your child)
Diabetes
 Asthma (breathing problems)
Bleeding problems
Vision issues (Glasses Contacts)
 Headaches/Migraines
Seizures or convulsions
Heart problems
 Hearing (Hearing Aids Yes No)
Frequent nosebleeds
Physical handicap
ADD/ADHD
Urine/bowel problems
 Other Please explain________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
3. ALLERGIES: Bees Foods Plants Drugs Animals Insects Other
Please describe the allergy and your child's reaction:
Emergency treatment needed? No Yes
Call 911
If yes, what treatment is needed? Medication:
4. MEDICATION:
Is medication taken for any health problem? No
Yes (Describe)
Taken at
Home
Is your child's physical activity limited in any way? No
Parent Signature
School
Yes (how)
Date
 I need information regarding low-cost health insurance.
Present Grade Level:
Teacher:
Room #:
×

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