Beebe High School Student Health History
Student LAST Name *
Your answer
Student FIRST Name *
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Student MIDDLE Name *
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Student grade *
Student Date of Birth *
MM
/
DD
/
YYYY
Student Age *
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Student Gender *
Emergency Contact *
Your answer
Relationship of Emergency Contact *
Your answer
Emergency Contact Phone Number *
Your answer
If parents or the emergency contact listed cannot be reached, does the school have the parents' consent to take the child to a doctor or hospital for treatment? It is understood that the parent is responsible for all medical expenses involved. *
Physican *
Your answer
Phone *
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Preferred hospital *
Your answer
Does your child have a medical condition of which we should be aware? *
Please check all that apply
If "other" please explain
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List other conditions
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List all current medications:
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Will medication be required during school hours? (If "yes", please complete medication request form available from your school nurse)
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