JOHN HERSEY HIGH SCHOOL – CHORAL DEPARTMENT

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

Month Day Year
Date
Address

ADDRESS

Street Address Line 2

CITY/STATE/ZIP
HOME PHONE
CELL PHONE
PARENT/GUARDIAN NAMES
BUSINESS PHONE
Mother
BUSINESS PHONE
Father
BUSINESS PHONE
Guardian
CELL PHONE
Mother
CELL PHONE
Father
CELL PHONE
Guardian
EMERGENCY CONTACT other than parent
PHONE
FAMILY PHYSICIAN
OFFICE PHONE
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

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

JOHN HERSEY HIGH SCHOOL – CHORAL DEPARTMENT – STUDENT HEALTH HISTORY