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Student Health Record (SS105)
* Indicates required question
Email
*
Record my email address with my response
Student's Name:
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Your answer
Date of Birth
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MM
/
DD
/
YYYY
Place of Birth
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Your answer
Heath Card Number
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Your answer
Family Doctor
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Your answer
Family Doctor's Phone Number
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Your answer
Father's Name
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Your answer
Mother's Name
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Your answer
Address:
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Your answer
Phone Number
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Your answer
Does your child have any chronic disease, allergy or other health problems that the administration needs to be aware of, or that may interfere with emergency medical treatment? If yes, please specify.
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Your answer
Does your child have any allergies? If yes, Please specify
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Your answer
Does your child use an epipen or any other medications? If yes, please specify.
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Your answer
Has your child had any of the following diseases? (Please check all that apply)
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Mumps
Red Measles
German Measles
Diphtheria
Poliomyelitis
Whooping
Cough
Tuberculosis
Hepatitis
Chicken Pox
Not Applicable
Required
Does you child have, or has had any of the following medical conditions?
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Asthma
Urinary Disorder
Headaches
Fainting
Convulsions
Heart Trouble
Constipation
Diabetes
Stomach Aches
Ear Aches
Eating Disorder
Eczema
Not Applicable
Other:
Required
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