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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
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Student Name
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Birthdate
MM
/
DD
/
YYYY
Grade
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Does your child have any medical problems or illnesses?
Yes
No
Clear selection
If yes, please specify.
Your answer
Does your child have any mental health or behavioral needs?
Yes
No
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If yes please specify.
Your answer
Does your child take any medications?
Yes
No
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If yes, please specify:
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Does your child have any allergies?
Yes
No
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If yes please specify:
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Does your child have asthma?
Yes
No
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Does your child have a prescribed Epi-pen?
Yes
No
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Has your child ever had a seizure?
Yes
No
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Does your child have any hearing or vision concerns?
Yes
No
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If yes, please specify:.
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