2018-2019 Student Health Update
The Student Health Update Must be completed for each student enrolled in the Madrid Community School District
Student Legal Last Name *
Your answer
Student Legal First Name *
Your answer
Student Date of Birth (mmddyyyy) *
MM
/
DD
/
YYYY
Grade for 2018-2019 *
Your answer
List any illness or injury your child has had that required hospitalization or major health interventions:
Your answer
Health History Update: please check all that apply
If you checked any of the above questions, please explain severity of the problem and any treatment regiment to be followed. List all medications taken, even if not at school, that may have side-effects that we need to be aware of. A signed consent form must be be provided for all medications given at school.
Your answer
Date of last physical: *
MM
/
DD
/
YYYY
Date of last eye exam: *
MM
/
DD
/
YYYY
Date of last dental exam: (submission of state form is required for all kindergarten and 9th grade students) *
MM
/
DD
/
YYYY
Date of last lead test: (required for all kindergarten students)
MM
/
DD
/
YYYY
Family Physician Name *
Your answer
Family Physician phone number: *
Your answer
Name of parent/guardian completing health update: *
Your answer
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