EmailMeForm
Current Health Information
The answer to these questions will let us know if your child has any medical problems. We need this information in the event your child becomes ill and we are unable to reach you immediately.
Child's Name
*
First
Last
Date of Birth
*
MM
/
DD
/
YYYY
Has your child been hospitalized in the last 12 months?
*
Yes
No
If your child has been hospitalized in the last 12 months, please explain.
Is you child taking any medication?
*
Yes
No
If your child is taking any medication, please list:
Does your child have any allergies or allergic reactions to medications or to insects?
*
Yes
No
If your child does have allergies or known allergic reactions, please describe:
Does your child have asthma-like symptoms?
*
Yes
No
Does your child have speech or hearing problems?
*
Yes
No
Has your child had more than two ear infections in a year?
*
Yes
No
Has your child had tonsillitis?
*
Yes
No
Does your child have trouble with his or her eyes or vision?
*
Yes
No
Has your child had a bladder or kidney infection?
*
Yes
No
Does your child have burning when urinating?
*
Yes
No
Does your child have seizures, fits, or shaking spells?
*
Yes
No
Have you ever been told that your child has a heart murmur?
*
Yes
No
Has your child ever had a reaction to a TB skin test?
*
Yes
No
Has your child ever been in close contact with anyone diagnosed with TB?
*
Yes
No
Has your child ever had worms?
*
Yes
No
Does your child scratch his or her genital area excessively?
*
Yes
No
Is your child a hemophiliac?
*
Yes
No
Is your child on a heart monitor?
*
Yes
No
Does your child have tubes in his or her ears?
*
Yes
No
Does your child get along with other children?
*
Yes
No
Is your child usually happy?
*
Yes
No
Has your child developed any special problems in the last 12 months not indicated above?
*
Yes
No
If your child has developed any issues in the last 12 months not indicated above, please describe:
When did your child last see a doctor?
*
MM
/
DD
/
YYYY
Does your child have any dietary restrictions?
*
Yes
No
If your child does have dietary restrictions, please list or describe them completely.
Parent/Guardian Signature
*
First
Last
Please enter your parent/guardian name to sign electronically and indicate that to your best knowledge the health information provided above is complete and up-to-date.
Date Completed
*
MM
/
DD
/
YYYY