Student Information Form Page 2
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1
2MEDICAL INFORMATION
Are there any medications taken on a regular basis?
Yes
No
Are there any medical or behavioral problems the Preschool Teacher should be aware of? If so, please provide
details.
Allergies: _________________________________________________________________________________
Doctor’s Name: _________________________________ Phone Number ______________________________
Address: __________________________________________________________________________________
Alberta Health Care Number: __________________________________________________________________
**** Please provide photocopy of Alberta Health Care Card ****
Hospitalization: _______________
___________________________________________________________
Date
Diagnosis
Public Health Clinic Attended for Vaccinations
___________________________________________________________
**** Please provide photocopy of vaccination record ****
Childhood Illnesses ( please mark in date if child has had any of the following)
Measels
Bronchitis
Rubella
Chicken Pox
Head Injury
Fracture
Whooping Cough
Accidental Poisoning
Mumps
Ear Infection
Convulsions
Other (please specify) __________________________________________________________________
Parent Signature:
_____________________________________________
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