Home Address:__________________________________________________________________________
Parent/Guardian Full Name: ______________________________________________________________
Home Phone:______________________Cell Phone__________________ Pager:____________________
In Emergency Notify: __________________________________________at__________________________
(Name & Relationship) (Phone number with area code)
If they are not available, notify: __________________________________at_________________________
(Name & Relationship) (Phone number with area code)
Family Physician: _____________________________________________at__________________________
(Name) (Phone number with area code)
Insurance Company Name: _____________________________ Phone Number:_______________________
Section 1: Illnesses and injuries (check those that apply and explain below)
Chronic or Recurring illness
_______Ear Infection ________Bleeding/Clotting Disorders________Hypertension __________Asthma
Heart Defect/Disease_______Seizures_______Diabetes
________ other (specify and explain)________________________________________________________
Date of last Health Exam:______________________ Were any complicating medical problems or any
conditions requiring monitoring or follow-up noted in the last health exam?__________Explain on a
separate piece of paper.
Is child currently under the care of a physician or psychologist?_______________
Since the last health exam, has child had:
An injury or medical condition requiring medical attention?_____ An illness lasting more than five days?_______
Any exposure to a contagious disease?_________ A surgical operation or fracture?_________
Treatment in a hospital, outpatient clinic, or emergency room?____________Any restrictions of
physical activities?___________
Any prescribed or over-the-counter medications?__________ Is child currently taking any
medication?________
