MEDICAL HISTORY

Name ____________________________________________ DOB _________________ Age ______ years

Medical Diagnoses: __________________________________________________________________________

__________________________________________________________________________________________

Allergies and (reactions): _____________________________________________________________________

__________________________________________________________________________________________

Medications-Daily and/or as needed and dosing: __________________________________________________

__________________________________________________________________________________________

If ______________________ experiences a change in health condition (such as a change in medication, new diagnosis or hospitalization) please contact the school, so that the HEALTH CARE HISTORY page can be revised, if needed. Parent/guardian signature indicates permission to contact the child’s health care provider listed above, as needed. The signature also indicates an understanding that the health history may be shared with necessary school personnel on a need-to-know basis, to help ensure this child’s safety and well-being while at school or during school related activities.

Parent/Guardian Signature ____________________________________________________ Date ___________

School Nurse Signature _______________________________________________________ Date ___________

Administrator Signature ______________________________________________________ Date ___________

EMERGENCY CONTACT INFORMATION

Parent/Guardian & Contact numbers: ______________________________________________________________________________________________________________________________________________________________________________

Home Address:__________________________________________________________________________

Emergency contact (people we try after we try the parents):

1._____________________________________________________________________________________

2._____________________________________________________________________________________

Health Care Provider name, contact number and address: ______________________________________________________________________________________________________________________________________________________________________________

Hospital preference:______________________________________________________________________

**Willis Knighton South is closest to WOGA.