Health History Checklist
Today's Date
*
-
Month
-
Day
Year
Date Picker Icon
School Year
*
Please Select
2023-2024
2024-2025
Child's Name
First Name
Last Name
Child's Date of Birth
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Month
-
Day
Year
Date
Guardian's Name
*
First Name
Last Name
Guardian's Relationship to Child
Mother
Father
Grandmother
Grandfather
Other
Select each of the following conditions that apply to your child.
Please provide an explanation for any checked item.
Guardian's Signature (Use your mouse to sign.)
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