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STUDENT MEDICAL REPORT

Student’s Name:  
Date of Birth:  
Gender:  
Blood Type:  
Height:   Weight:   Hair Color:   Eye Color:  
1. Special medical conditions __________________________________________
2. Chronic illnesses __________________________________________
3. History of serious injuries or hospitalizations of which we should be aware __________________________________________
4. Diabetes Yes No
5. Medication that will be administered regularly at school __________________________________________
6. Physical Restrictions __________________________________________
Please note if your child had any of the diseases listed below
 
Date
Bronchiolitis/pneumonia __________________________________________
Chicken Pox __________________________________________
Hepatitis __________________________________________
Scarlet Fever __________________________________________
Mumps __________________________________________
STUDENT’S MEDICAL CARE PROVIDER/ FACILITY
 
Student’s Doctor Name: _______________________ Clinic Name: ___________________________
Doctor’s address: __________________________________________
Private Health Insurance Provider and Policy Number: __________________________________________