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Clinic Information 2022-2023
Please fill out the information below for your child that attends Middle Ridge Elementary.
Please complete one for for each child.
A copy of this information will be sent to your child's teacher.
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* Indicates required question
Name of person filling out this form and relationship to student.
*
Your answer
Student Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Grade
*
Choose
PreK
Kindergarten
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
Other
Homeroom Teacher
Your answer
Name of Siblings enrolled at Middle Ridge
*
Your answer
HEALTH HISTORY
If you answer YES to any questions please explain
Allergies-Please list all, if none please type N/A
*
Your answer
Drug Allergies/Reaction-Please list all, if none please type N/A
*
Your answer
My child received immunizations this past year. If YES please list type and date. If none please type N/A
*
Your answer
My child takes prescribed medications routinely/occasionally. If YES please list type and date. If none please type N/A
*
Your answer
My child needs an inhaler/nebulizer available at school. (If YES, provide medication to keep at school)
*
Choose
Yes
No
My child requires an Epi-Pen for severe allergic reaction. (If YES, please proved Epi-Pen to keep at school)
*
Choose
Yes
No
Please mark Yes or NO for each illness below that your child has.
*
Yes
No
Asthma
Cancer
Diabetes
Seizure
Menstrual
Kidney Problems
Migraine Headaches
Physical Handicaps
Skin Condition
Heart Problems
Other
Yes
No
Asthma
Cancer
Diabetes
Seizure
Menstrual
Kidney Problems
Migraine Headaches
Physical Handicaps
Skin Condition
Heart Problems
Other
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