Cohen / Doughty Medical History Update Form (to be filled out annually by parent/guardian)
This form covers known family health history information and is to be filled out annually by a parent/guardian to the best of their ability. 


**A Sports Physical is only required for those students wishing to tryout for / participate in an interscholastic sport (and not necessary for clubs, activities, and intramural offerings). The Physician Form is located here. Alternatively, you may contact your child's primary care provider and ask them to fax a note to the school that includes the most recent physical date, stating the student is cleared for full participation in athletics. Sports physicals completed after a student finishes grade 5 will be honored for grades 6th, 7th, and 8th. A physical completed during grade 5 will be honored for one calendar year from that examination date. 
Email *
Has / Is your child: (please check yes or no) *
YES
NO
Under a physician's care now?
Taking any medications?
Ever had injuries requiring medical attention?
Ever had a surgical operation?
Ever stayed overnight in a hospital?
Allergic to any foods, medications, insect bites, or other substances?
If you answered YES to any of the above, please explain: 
Does your child wear contact lenses?  *
Has your child seen a dentist in the last 6 months?  *
Most recent Tetanus Toxiod immunization: *
MM
/
DD
/
YYYY
Was this a Tetanus booster? 
Clear selection
Has your child had any of the following:  *
YES
NO
Asthma
Diabetes
High Blood Pressure
Heart Murmur
Rheumatic Fever
Convulsions or Epilepsy
Migraine Headaches
Kidney or Bladder Trouble
Hernia
Tendency to bruise or bleed easily
COVID-19?
Please explain any "YES" answers above (write N/A if all "NO") *
Has anyone in your immediate family had any of the following:  *
YES
NO
Asthma
Diabetes
High Blood Pressure
Heart Murmur
Rheumatic Fever
Convulsions or Epilepsy
Migraine Headaches
Kidney or Bladder Trouble
Hernia
Tendency to bruise or bleed easily
Please explain any "YES" answers above (write N/A if all "NO") *
by checking the E-Signature box below I confirm this information is accurate and complete to the best of my knowledge. *
Required
Parent Name (first and last) *
Date Signed *
MM
/
DD
/
YYYY
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