Student Health History Questionnaire
Student Information
Full Name
Date of Birth
Grade
Parent/Guardian Name
Phone Number
Email Address
Medical History
Has the student ever had any of the following? (Check all that apply)
Asthma
Diabetes
Seizures
Allergies
Heart Condition
Other
If selected any, please provide details
Has your child had any operations, hospitalizations, or serious injuries?
Yes
No
If yes, please describe
Allergies & Medications
Does your child have any allergies?
Yes
No
If yes, please list
Does your child take any medications (including inhalers, insulin, epi-pen, etc.)?
Yes
No
If yes, please list name and dosage
Other Health Information
Are there any activities your child should not participate in?
Other health concerns or information the school should know