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Hutchinson Public and Parochial School
Student Health Form

MINNESOTA LAW REQUIRES STUDENTS BE UP TO DATE WITH IMMUNIZATIONS IN ORDER TO ENROLL IN SCHOOL.
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School Year
Student Name
Birthdate
MM
/
DD
/
YYYY
Grade
Does your child have any medical problems or illnesses?
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If yes, please specify.
Does your child have any mental health or behavioral needs?
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If yes please specify.
Does your child take any medications?
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If yes, please specify:
Does your child have any allergies?
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If yes please specify:
Does your child have asthma?
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Does your child have a prescribed Epi-pen?
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Has your child ever had a seizure?
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Does your child have any hearing or vision concerns?
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If yes, please specify:.
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