Health History Form

Please complete the form below. Required fields marked with an asterisk *

Student Name*

Answer Required

D.O.B*

Answer Required

Gender*

Answer Required

Address

Street Address*

Answer Required

City*

Answer Required

Zip/Postal*

Answer Required

Grade*

Answer Required

Contact Information - Parent\Guardian

First Name*

Answer Required

Middle Name

Answer Required

Last Name*

Answer Required

Email 1*

Answer Required

Phone*

Number Required

Contact Information - Parent/Guardian

First Name

Answer Required

Middle Name

Answer Required

Last Name

Answer Required

Email 1

Answer Required

Email 2

Answer Required

Mobile Phone

Number Required

Home Phone

Number Required

Work Phone

Number Required

Please provide information regarding checked boxes

Answer Required

Please indicate any other medical issues not mentioned above

Answer Required

Please list any medications taken by the child along with dosage and frequency

Answer Required

Family Doctor*

Answer Required

Hospital Preference*

Answer Required

Signature*

Signature Required

Please fix the highlighted areas below before submitting.

Health History Form