Patient Medical Information Form

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PEN# ______________________
MEDICAL INFORMATION FORM (1)
STUDENT INFORMATION
Gender
Male
Female
Student Name
Birthdate (DD/MM/YY)
Parent/Guardian Name
Parent/Guardian Home Phone #
Parent/Guardian Business Phone #
Emergency Contact Name/Phone
Physician Name/Phone #
HEALTH INFORMATION
Please indicate by checking the applicable box if your child has any of the following medical conditions or any other
serious health concerns, or requires medication to be administered at school.
Medical Condition
Hearing Impairment specify:
Visual Impairment specify:
Physical Impairment specify:
Serious Health Concerns
Life Threatening Allergies allergic to:
(parent required to fill out form 1A)
Diabetes
(parent required to fill out form 1B)
Asthma
(parent required to fill out form 1C)
Seizure Disorders
(parent required to fill out form 1D)
Other Serious Health Concerns specify:
Medication that is essential for school staff to give students during school hours
My child requires medication to be administered by school staff (parent required to fill out form 1E)
IMMUNIZATION
It is important to protect your child against certain communicable diseases. In addition to recommended
childhood immunizations that most children have received, the following immunizations are provided for grade 6
and grade 9 students at a school clinic: Hepatitis B, Meningococcal C and Chickenpox. In addition Grade 9
students will receive Tetanus, Diptheria and Pertussis. A request for parental consent will be sent home prior to
the school clinic. Following an immunization clinic at your school, your child will be given a notice of immunization
that can be added to his/her medical records at home.
Parent/Guardian Signature _________________________________________ Date Completed ________________________

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