Student Health Form
Student’s Name ____________________________ Grade ____ Sex: M or F
Date of Birth: _____________________________ Social Security #: _____________
Address: _______________________________________________________________
Parent/Guardian: _______________________________ Phone: ___________________
Parent Address (if different) __________________________ Phone: _______________
Emergency Contact: ________________________________ Phone: ________________
HEALTH HISTORY
Serious Medical Problems: _________________________________________________
Does Your Child Have Asthma? ________________ Medication: _________________
Date of Last Tetanus Shot: ________________ Any Food Allergies: _______________
Can Your Child Swim? _____ Is Your Child a Vegetarian? ______
Family Physician: ____________________________ Phone: _____________________
Insurance Company: ____________________ Contact Info: ______________________
Name of Insured: ________________ Policy #: _______________ Group#: __________
*DOES YOUR INSURANCE REQUIRE PRECERTIFICATION? Yes – No Ph#
___________
I GIVE THE CHAPERONES PERMISSION TO ADMINISTER THE FOLLOWING OVER
THE COUNTER MEDICATIONS IF NECESSARY:
Advil: _____ Tylenol: _____ Benadryl: _____ Aspirin: _____
Imodium: _____ Aleve: _____ Bonine: _____ Imitrol: _____
Pepto Bismol:
_____ Dramamine: _____ Sinus/Cold meds: _____
Other Medications: ________________________________
Parent Signature: __________________________________ Date: ___________