Middleton Cross Plains Area School District Physical And Dental Form printable pdf download

Middleton-Cross Plains Area School District

Physical and Dental Form

TO BE FILLED OUT BY PARENT/GUARDIAN

Child’s Name: ____________________________________

Birthdate:_______________Sex ______

School:________________ Grade:_____

Parent/Guardian:_________________________________

Address:________________________________________

________________________________________

Phone: ________________ Home __________________

Primary Physician:________________________________

Date of last visit: ____________________

Clinic Name:

______________________________

Clinic Address: ________________________________

________________________________

Phone:

________________________________

Dentist’s Name: _________________________________

Date of last visit: ____________________

Address:

_________________________________

Was dental treatment completed?

Phone:

_________________________________

Yes _____ No ____ Not needed ____

In an effort to provide a safe, healthy environment for your child at school, we would like to know about your

child’s health needs.

Have there been any major changes in the family situation in the last year, such as a family moving,

loss of someone close, or a serious illness of either parent? Yes ____ No ____ If yes, please

describe:

Has your child had any serious accidents, illnesses, hospitalizations or injuries in the past year? Yes

____ No ____ If yes, please describe:

Please describe any health concerns or medical diagnosis your child may have (i.e. asthma, seizure

disorder, diabetes, hearing or vision concerns, or any health concern).

Does your child take any medications regularly? Yes ____ No ____ If yes, please list.

Please give any additional comments/information that you would like to share about your child.

Has there been any tuberculosis exposure? Yes ____ (yr _______) No ____. If yes, please describe

treatment.

May this information be shared with appropriate school personnel, as determined by the school nurse?

Yes ______ No _____

If your child has a health concern, may this information be included on a health concern list that is distributed

to staff and maintained in the school health office? Yes ____ No ____

Signature of Parent of Guardian: _______________________________________Date:_________________

PLEASE RETURN TO YOUR CHILD’S SCHOOL HEALTH OFFICE

02/99.03

F:\Users\RobertaM\Forms\Health Services Forms\03 Physical and Dental Form.wpd

(OVER)

Middleton Cross Plains Area School District Physical And Dental Form

Related Articles

Related forms

Related Categories