Your child’s learning depends upon good health. To assist in providing health services at school, please complete the following form.
First: Middle:
Health Care Providers
Doctor’s Name:
Date of Last Visit:
Dentist’s Name:
Date of Last Visit:
Is child currently under orthodontist care?
Y N Orthodontist Name:
Hospital Preference:
Please check ALL over-the-counter medications you authorize your child to receive at school.
Tylenol/ Acetaminophen
(Decongestant, Antihistamine, Cough Suppressant) (Phenlephrine HCL, Bromphiramine maleate, Dextromethorphan) Please list child’s current medications
Reason for taking
Will your child require medications at school?
Office Use: Attached Medication Form
Illness/ Accident/ Hospitalization/ Surgery
Please indicate IF and WHEN your child had:
Chickenpox: Yes / No Date: ____/____/____ Measles: Yes / No Date: ____/____/____ Mumps: Yes / No Date: ____/____/____
Has your child ever had: Major Illness Serious Accident Hospitalizations Surgeries
If yes, please explain providing month and year:_________________________________________________________________________
Growth Development
Did you have any problems during the pregnancy? If yes, Please explain:
Were there any problems at the time of the birth of your child? If yes, Please explain:
Did your child meet the normal developmental stages such as crawling, walking, talking as expected? If no, Please
Health Concerns Chadwick
Has your child in the past or present had any problems with the following: If yes, Please explain:
Y N Crossed/ Drifting Eyes:
Itching/ Burning/ Redness:
Excessive Tearing/ Watering:
Wear Glasses/ Contacts:
Y N Seasonal Allergies:
Post Nasal Drip:
Sinus Congestion:
Frequent Nose Bleeds:
Y N Frequent Ear Infections:
Difficulty Hearing:
Wears Hearing Aid: Right Ear Left Ear Both
Chronic Cough/ Chronic Bronchitis:
*Asthma: What triggers an asthma attack?
*Does your child use an inhaler(s) on a daily basis? Name of inhaler:
Thyroid Disorder:
Y N  Do they take insulin?
How often is blood sugar checked?
Bleeding Disorder:
Headaches/ Migraines:
Seizures: Date of last seizure ____________
Presently under doctor’s care?
Currently taking medication for seizures
Heart Condition:
Heart Murmur:
Y N Stomach Problems:
Diarrhea/ Constipation:
Dietary Restrictions:
Special Diet:
Y N Kidney Disorder:
Frequent Bladder Infections:
Needs to use bathroom frequently:
Bed Wetting:
Y N Requires Diaper/ Cauterization:
Rheumatoid Arthritis:
Muscle Disorder or Pain:
Bone or Joint Disorder or Pain:
Y N Skin Disorder/ Scars:
Your child’s doctor will need to provide documentation stating restrictions
Y N Any Condition that prevents P.E.
Office Use: Documentation Provided:
I give my permission for the above health information to be shared with appropriate school personnel on a confidential I have read the Medication Administration Policy and Procedure Form. I request and authorize Chadwick School to administer medication to the above student in accordance with the over-the-counter age/ weight specific dosing ____________________________________________________________________



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