Student Health History
To be completed by the parent/guardian
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電子郵件 *
Name of Student *
Student's Grade *
Student's Primary Healthcare Provider *
Student Primary Health Care Provider Phone Number *
Student's Dentist
Student's Dentist's Phone Number
Student's Healthcare Insurance Provider
Does the student have allergies to any food? *
Does the student have allergies to any medication? *
If your student has any allergies, please explain here. Also please leave the student's treatment for their allergies.
Does the student take any medications? *
If your student takes medications, please explain here
Has the student had chickenpox? *
Does your family have any major health problems? *
If your family has major health problems, please explain here
Does your student have any hearing issues? *
Does your student have any vision issues? *
If your student has any hearing or vision issues please explain here
Please check off any of the following illness or conditions your student has had. *
必填
If you checked off any of the boxes above, please explain here *
Name of Parent of Guardian filling out the form *
Best contact for parent/guardian filling out the form *
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