DATE_____________________

Lebanon Catholic School

Student Health Information

Student’s Name______________________________________ M/F_____ Grade______

Last First

Birth date________________________________________ Telephone________________

Address_________________________________________________________________

Parent’s Name: Father______________________________________________________

Last First M.I.

Mother_____________________________________________________

Last First Maiden Name

Has your child had any childhood illnesses?	Yes No
Does your child have heart problems?	Yes No
Does your child have diabetes?	Yes No
Has your child had any trouble with ears or hearing? If yes, what age? _________	Yes No
Has your child had any trouble with eyes or seeing? If yes, what age? _________	Yes No
Has your child ever had a convulsion? If yes, explain______________________________ At what age? ________	Yes No
Does your child have allergies? f yes, name___________________________	Yes No
Does your child have asthma? If yes, name medication________________________	Yes No
Has your child ever had a reaction to any medicine or injections? _______ If yes, name medication________________________	Yes No
Has your child ever been in the hospital? ______ Reason________________________________ When______________ Name of Hospital__________________	Yes No
Has your child had any accidents, broken or fractured bones? _________ Explain____________________________________________ When__________________________________	Yes No
Is your child under doctor’s care at present? ______________________ Reason___________________________________________ Physician____________________________________	Yes No
Is your child taking medicine other than vitamins? __________________ If yes, what medicine_________________________________	Yes No
Previous school attended______________________________________	Yes No