St Mary's School Student Health Form
Immunization Status:  Submit a photocopy of your child's most up to date immunization records to St Mary's School office.
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Student Name (First Middle Last) *
Student Birthday *
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Student Grade Level *
Is your child currently under any medical treatment or taking any type of medication? *
If the above answer was "Yes", please tell us the medication name(s) and treatment(s) associated.
Does your child have any special health problems the school should know about? *
If the above answer was "Yes", please specify below the health issue.
Student Pediatrician or Family Physician Name *
Student Pediatrician or Family Physician Phone Number *
Student Dentist Name *
Student Dentist Phone Number *
Date of Last Physical Exam *
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Date of Last Dental Exam *
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Date of Last Eye Exam *
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Date of Last Lead Risk Assessment *
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If there are any allergies, please list specifically below (ex:  specific food, drug, bee/insect, environmental) *
Does your child have any of the following: *
Required
If you answered "Other" to the above question, please specify below:
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