Student Medical Information Sheet 22-23

Student's Last Name

Student's First Name

MI

Student's Gender Assigned at Birth

Date of Birth

Date

Grade Level

Address

Mailing address

Street Address Line 2

City & State

Previous School (If new student)

Father's Name

Phone Number

Workplace

Workplace Phone Number

Mother's Name

Phone Number

Workplace

Workplace Phone Number

Siblings in Anna District 37

Student resides with:

Emergency Contact #1 (will be called after parents/guardian)

Phone

Relationship to student

Emergency Contact #2

Phone

Relationship to student

Student's Physician/Medical Provider

City/State

Medications taken at home

Medications to be taken at school

Does student have asthma?

Inhaler to be taken at school?

Does the student have diabetes?

Insulin Type

Does the student wear glasses or contacts?

Does the child have a hearing aid?

Does the student have seizures?

If yes, please describe seizures and what type of emergency medications they may take.

List all student allergies to medications, environment, bees/wasp, etc.

Does the student have an Epinephrine Pen?

Does the child have food allergies?

Please list your student's food allergies.

What type of specific reaction does your child have or has had to each food listed above?

Does your child have any other dietary restrictions or a special diet?

Please describe any special diets or dietary restrictions.

Parent/Guardian Signature

Clear

Date

Please note: Any information on this medical information sheet may be shared with appropriate personnel for health and educational purposes.