South School Summer Program Health History Form
Please provide as much information about your student so we can meet their medical needs safely and efficiently.
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Student's Name - First & Last *
Students Current School *
Student's Current Grade *
Students Date of Birth *
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DD
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Parent/Guardian's Name *
Parent/Guardian's Phone Number *
Student's Primary Care Physician *
Date of Last Appointment
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DD
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YYYY
Student's Dentist
Date of last Appointment
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DD
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YYYY
Does your child have any known medical issues? *
If yes, please list:
Does your child have any significant allergies? (Food, insects, medications, etc)? *
If yes, what are they and what are the reactions? Indicate if medication is needed.
Does your child have any known vision or hearing problems? *
Please indicate if your child has glasses, contacts, hearing devices, or other assistive devices related to vision and hearing.
Is your student currently taking any medications or inhalers? *
If yes, please explain which medication and if they will need to be taken during the summer program hours:
Within the past year has you child had a significant injury (Concussion, fracture, dislocation), developed a new illness, or had surgery or hospitalization? If yes, please indicate and explain: *
Does your child have any health concerns you wish to consult with the nurse about?
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