Student Medical Condition Reporting

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Please list any and all medical condition(s) your student suffers from. (including seasonal allergies, migraines, etc). This will assist the nursing department with establishing a baseline for your student when assessing Covid-19 Symptoms.

Student Name *

Student Grade *

Please list any Allergies (Medication, Food, Environmental) that your student has and if they require an Epi Pen. *

Please list any and all medical conditions your student has been diagnosed with by a primary care provider. *

Please list any and all medications your student takes on a regular basis. *

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