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Microsoft word - student health record 2008-2009.doc


Full Name: _____________________________________ Parent/Guardian Name: ____________________________________
Birthdate: ___ / ___ / ___ Home Phone: _________________ e-mail address: ____________________________________

Work Phone (Father): _____________________ (Mother): ___________________ (Step-Parent): _____________________
Physician’s Name: _______________________________ Telephone Number: ______________________________________
PARENTAL SIGNATURE : ____________________________________________________________________________
Student must be covered by MEDICAL INSURANCE to participate.

Insurance Policy Holder’s Name: ___________________________ Insurance Company: _______________________________
Policy #: _______________ Is student covered by medical insurance? Yes :  No : 
Dentist’s Name: ______________________________ Telephone Number: __________________
Dental Insurance Company: _______________________ Policy # ______________
Have any of your close relatives (parents, siblings) suffered serious diseases such as, but not limited to, cancer, heart disease,
diabetes, mental disorder, or epilepsy?
Please explain: __________________________________________________________________________________________
Have you ever been hospitalized, seriously injured, or operated upon? ____________________________________________________________________________ Do you have a problem with allergies or allergic reactions to foods, drugs, or other agents? ____________________________________________________________________________ Have you had a chronic illness that required prolonged medical care? Do you take daily medication at present?  ____________________________________________________________________________ Have you ever suffered from an emotional illness, bad nerves, or been under psychiatric care? ____________________________________________________________________________ Do you need emergency medication in school? (If yes, please list drug’s name and reason for dispensing)
SYMPTOM REVIEW (To be filled out by student) - In the past year, have you:
1. Had frequent colds, chronic coughs, or ear troubles?   7. Had loss of appetite or unexpected weight loss?  2. Had severe headaches, dizzy spells, or blackouts?  8. Worried alot? Are there problems at home?   3. Ever fainted after participating in a sports event? 4. Are you often tired, weak, fatigued, or short of breath?  5. Do you have frequent abdominal pains, or diarrhea?  6. Have you noticed blood or painful urination? 12. Is there anything concerning your health you would like to discuss with the Doctor? (Please discuss)
#12. Discussion : _________________________________________________________________________
Please explain any “yes” answers (except #10), please specify number.
MEDICAL EXAMINATION (To be filled out by a Medical Practicioner)
1. Does the child have a diagnosed medical condition?
If yes, please explain _____________________________________________________________ 2. Does the child have a health condition which may require EMERGENCY ACTION while he is at school? (e.g. seizure, allergy, asthma, bleeding problem, diabetes, heart problem) If yes, please explain _____________________________________________________________ 3. Are there any abnormal findings on evaluation for concern? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 5. If yes, please indicate : ___________________________________________________________ If yes, please specify nature and duration : ___________________________________________ 8. Please specify below any over the counter medication that can be dispensed to the child. (Discuss with Parent/Guardian) Medication Yes No Medication Yes No
M.D. Signature: ____________________________________________ Date: ___________________

Source: http://www.msjnet.edu/uploaded/PDF's/Student_Health_Record_2008-2009.pdf

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