2022 Medical Form

2022 Medical Form
*PLEASE NOTE - If medical information is the same as what you filled out last year, simply fill out the student's name and click submit form.

Form effective dates: January 1st, 2022 to December 31st, 2022
Student Information:
Student's Name:

First NameMiddle NameLast Name
Birth Date:

MonthDayYear
Current Grade:

7th Grade8th Grade9th Grade10th Grade11th Grade12th Grade
Gender

MaleFemale
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Name

First NameLast Name
Home Number

Area CodePhone Number
Cell Number

Area CodePhone Number
E-mail
Emergency Information
1st Emergency Contact's Name

First NameLast Name
Relationship to Student:
Phone Number

Area CodePhone Number
Alt. Phone Number

Area CodePhone Number
2nd Emergency Contact's Name

First NameLast Name
Relationship to Student:
Phone Number

Area CodePhone Number
Alt. Phone Number

Area CodePhone Number
Medical Information
Medical Insurance Company
Policy #:
Physician:

First NameLast Name
Physician's Office Phone:

Area CodePhone Number
Dentist:

First NameLast Name
Dentist's Office Phone:

Area CodePhone Number
MEDICAL HISTORY
List any allergies
Do you suffer from, or have ever experienced, or are being treated currently for any of the following: (Check all that apply)

asthmafrequent upset stomachepilepsy/seizure disorderphysical handicapheart troublediabetes
Date of last tetanus shot:
Do you wear any of the following? (Check all that apply)

glassescontact lensesdenturesdefibrillator (left)defibrillator (right)hearing aids (left)hearing aids (right)
Please list and explain any major illnesses you have experienced during the last year:
Please list any medication and dosages:
In the box below, describe in detail the nature and severity of any physical and/or psychological ailment, illness, propensity, weakness, limitation, handicap, disability, or condition of which the staff should be aware, and what, if any action of protection is required on account thereof. Include names of medications and dosages that must be taken.
Answer here:
Parent Signature*

Clear
Today's Date:*

MonthDayYear
Should be Empty:

2022 Medical Form

MEDICAL HISTORY