Emergency / Health Information Form (Page 2 of 3) in pdf

Emergency / Health Information Form Page 2

Medical History

Are immunizations up to date? ________ (please provide documentation)

Does your child have any health concerns? _______________________________

__________________________________________________________________

Does your child take any medications on a regular basis? (if yes, please list name

and dosage) ________________________________________________________

__________________________________________________________________

Does your child have any known allergies? (if yes, please list) _________________

__________________________________________________________________

Do you have any hearing or vision concerns with your child? __________________

Does your child experience any of the following on a regular basis?

Nosebleeds _____

Headaches _____

Stomachaches _____

Seasonal allergies _______

Other ___________________________________

Has your child had any surgeries? (if yes, please list) _______________________

__________________________________________________________________

Are there any other medical concerns we should be aware of? ________________

__________________________________________________________________

Emergency / Health Information Form Page 2