Joel E. Barber Health Services Form
Student's FULL LEGAL Name *
Date of Birth *
Grade *
Gender *
Height and Weight
Does Student Have Insurance? *
If yes, please list Insurance Name
Health History: Please mark all that apply *
Has your child ever been hospitalized or had any kind of surgery *
If yes, please explain
Has your child ever had chickenpox? If yes, please list month/year of illness. *
Does your child eat 3 balanced meals per day? If not, please explain *
Does your child have allergies to food, medications, or environmental substances? *
If yes, how does your child react to the allergies?
Has your child ever been stung by a bee or wasp? *
If yes, please list the reaction
My child takes the following medications, homeopathic remedies, or supplements on a daily/regular basis
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