JOHN HERSEY HIGH SCHOOL – CHORAL DEPARTMENT

JOHN HERSEY HIGH SCHOOL – CHORAL DEPARTMENT – STUDENT HEALTH HISTORY
NAME
DATE OF BIRTH

MonthDayYear
Date
Address

ADDRESS

Street Address Line 2

CITY/STATE/ZIPState / Province

Postal / Zip Code
HOME PHONE
Format: (000) 000-0000.
CELL PHONE
Format: (000) 000-0000.
PARENT/GUARDIAN NAMES
BUSINESS PHONE
MotherFormat: (000) 000-0000.
BUSINESS PHONE
FatherFormat: (000) 000-0000.
BUSINESS PHONE
GuardianFormat: (000) 000-0000.
CELL PHONE
MotherFormat: (000) 000-0000.
CELL PHONE
FatherFormat: (000) 000-0000.
CELL PHONE
GuardianFormat: (000) 000-0000.
EMERGENCY CONTACT other than parent
PHONE
Format: (000) 000-0000.
FAMILY PHYSICIAN
OFFICE PHONE
Format: (000) 000-0000.
MEDICAL RELEASE (Student covered by group or other medical insurance):
NAME OF INSURED
INSURANCE COMPANY
GROUP#
POLICY#
SURGERY within the last two years
EMOTIONAL PROBLEMS ie hyperventilation, anxiety, etc
SERIOUS MEDICAL PROBLEM
MEDICATION TAKEN
ALLERGIES
DIABETES
NAME OF INSULIN TAKEN/AMOUNT/TIME
EPILEPSY
MEDICATION TAKEN/AMOUNT/TIME
ADD MEDICATION
TRANQUILIZERS
RHEUMATIC FEVER
ALLERGY TO DRUGS specify penicillin, insulin, sulfa, etc
WEARS GLASSES
WEARS CONTACTS
IS STUDENT PRESENTLY UNDER TREATMENT FOR A MEDICAL PROBLEM? IDENTIFY
PHYSICAL CONDITION WHICH MAY LIMIT ACTIVITY? IDENTIFY
HAS APPROVAL TO TAKEN OVER THE COUNTER MEDICATIONS
HAS APPROVAL TO TAKEN OVER THE COUNTER MEDICATIONS
LIST ANY OVER-THE-COUNTR MEDICATIONS YOU DO NOT WANT TO HAVE ADMINISTERED (ie allergic reactions or interaction with prescription drugs):
SPECIAL DIETARY NEEDS
SPECIFY
SPECIFY
DATE OF LAST TETANUS SHOT

MonthDayYear
Date
USE SPACE BELOW TO LIST ANY OTHER PERTINENT HEALTH HISTORY.
Should be Empty:

JOHN HERSEY HIGH SCHOOL – CHORAL DEPARTMENT – STUDENT HEALTH HISTORY