Student Health Information Form



Student Information

First Name
Last Name

Date of Birth
Gender

Grade
School Year


Father/Guardian Information

First Name
Last Name

Home Phone
Work Phone

Mobile Phone
Email

Address Line 1
Address Line 2

City/Town
State/Province
Postal/Zip Code


Mother/Guardian Information

First Name
Last Name

Home Phone
Work Phone

Mobile Phone
Email

Address Line 1
Address Line 2

City/Town
State/Province
Postal/Zip Code


Emergeny Contact Person Information

Please list the emergency contact persons other than parent/guardian.
First Name
Last Name
Contact Phone
Relationship to Student
1
 
 
 
 
2
 
 
 
 
3
 
 
 
 


Health Information

Please tick if the student suffer from any following conditions.
ADD/ADHD
Allergy to Food
Allergy to Bees/Insects
Asthma
Cerebral Palsy
Dental
Depression
Diabetes
Hearing Problem
Heart Condition
High Blood Pressure
Migraine Headaches
Seizure Disorder
Vision Problem


Medication Information

Please list all medications that the student is currently taking.
Medication Name
Dose
Reason
1
 
 
 
2
 
 
 
3
 
 
 
4
 
 
 
5
 
 
 
6
 
 
 
7
 
 
 
8
 
 
 
9
 
 
 
10
 
 
 


Parent/Guardian Authorization

Parent/Guardian Signature

Submit
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