Please answer the following questions as accurately as possible

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					Please answer the following questions as accurately as possible. Student Name________________________

Does your child have any of the following medical conditions?

   YES                NO

  _____              ______              Asthma
  _____              ______              Seasonal allergies
  _____              ______              Frequent sinus infections
  _____              ______              Frequent ear infections
  _____              ______              Epilepsy / Seizures
  _____              ______              Diabetes
  _____              ______              Nosebleeds
  _____              ______              Sickle Cell
  _____              ______              Bladder Problems
  _____              ______              Heart Problems:_____________________________________
  _____              ______              Kidney Problems:____________________________________
  _____              ______              Food Allergy      If yes, what food?_______________________
                                                           What type of reaction?____________________
  _____              ______              Drug Allergy      If yes, what drug?_______________________
                                                           What type of reaction?____________________
  _____              ______              Insect Sting Allergy If yes, what insect?_________________
                                                                  What type reaction?_________________

  _____              ______              Wears Glasses/contact lenses
  _____              ______              ADD, ADHD,ODC or ODD
  _____              ______              Eye condition or problems:______________________________
                                                     If yes, what?________________________________
  _____              ______              Ear condition or hearing problem:_________________________
                                                     If yes, what?________________________________
  _____              ______              Latex Allergy

  _____              ______              Lactose Intolerance

  _____              ______              Other Medical Conditions? _____________________________

  _____              ______              Physical Handicapping Condition? _______________________

  _____              ______              Has your child ever been in the Hospital? If yes, when?_______
                                         Reason for hospitalization ____________________________

  _____              ______              Does your child receive regular medical check-ups? If yes,
                                         where? _____________________________________________

CONSENT FOR RELEASE OF MEDICAL INFORMATION: If necessary, the school nurse has my
Permission to contact the health care providers listed for information concerning my child’s health.
_______________________________________________                              _______________________
Parent/Guardian Signature                                                      Date

Consent for school aged appropriate screenings

___________________________________________                              _______________________
Parent/Guardian Signature                                                 Date

				
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