Health Information Form

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Santa Clara Unified School District
HEALTH INFORMATION
Many students have physical conditions and/or health problems that need special
consideration. Arrangements can generally be made that benefit you if such
conditions are known. Please fill out this form carefully, it will help us to help you.
Student # ________________________________
Today’s date:_________________________
Name:____________________________________
Home Phone #________________________
Date of Birth:_____________________
Age:_______
Sex:_______
Grade:________
School last attended:________________________________________________________________
SchoolAddress:___________________________City:_________________State:_____Zip:_______
If out of the country, date of entry to the United States:_______________________________
Do you have any of the following problems?
Asthma
Yes_____No______
Heart Trouble
Yes______No______
Allergies
Yes_____No______
Hearing Difficulty
Yes______No______
Diabetes
Yes_____No______
Speech Difficulty
Yes______No______
Epilepsy
Yes_____No______
Vision Difficulty
Yes______No______
Do you have any limitations in physical education? Yes____No____
If so, what are your limitations?_____________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Do you wear glasses or contacts?
Yes_____ No_____
Are you in good health?
Yes_____ No_____
Are you taking any medication?
Yes_____ No_____
If yes, what medication(s) are you taking?___________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
When did you last see a doctor?__________________ Why?_____________________________
____________________________________________________________________________________
Doctor’s Name:_____________________________Health Insurance:_______________________

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