Student Health Form
Page 1 of 1
Student Health Form
1.
Student ID#
2.
Student First Name
*
3.
Student Last Name
*
4.
Grade
*
5.
Name of Person the person completing the medical information update.
*
6.
List any allergies the student has.
7.
List any special conditions the student has.
8.
I give permission for my child to be administered the following over the counter medications provided by the school.
Cough Drops
Ibuprofen (Advil, Motrin)
Acetaminophen (Tylenol)
Antacid (Tums)
Diphenhydramine HCL (Benadryl)
Ambesol
Sore Throat Spray
Sunscreen
Insect Repellant
Other, please specify
9.
Physician Information
Doctor's Name
Doctor's Phone Number
10.
Dental Information
Dentist's Name
Dentist's Phone Number