Roncalli High School Medical History and Permission Form for International Students
Student Name (Surname, Given Name) *
Your answer
Date of Birth (Day/Month/Year) *
Your answer
Host Family's Address
Your answer
Host Family's Telephone Number
Your answer
Student's Insurance Policy Carrier *
Your answer
Student's Insurance Number *
Your answer
Does the student have a history of...
Allergies *
Allergies - Medical Alert
If yes to allergies, is the student allergic to bees?
If yes to allergies, is the student allergic to the environment?
If yes to the environment, what in the environment (example - pollen, plants, etc.)?
Your answer
If yes to allergies, is the student allergic to any foods?
If yes to foods, what specific type(s) of foods?
Your answer
If yes to allergies, is the student allergic to any medication?
If yes to medication, list the name(s) of the medication(s).
Your answer
List any other allergies not mentioned above.
Your answer
Is treatment needed for any allergies?
Please explain the treatment that is needed.
Your answer
Does the student have a history of (continued)...
Attention Deficit Disorder *
Attention Deficit Hyperactivity Disorder *
Asthma *
Back or Neck Problems *
Behavioral Problems *
If yes to behavioral problems, please explain.
Your answer
Cerebral Palsy *
Chronic Skin Problems *
Concussions *
If yes to concussions, how many?
Your answer
Diabetes *
Dyslexia *
Eating Disorders *
If yes to eating disorders, what type?
Your answer
Emotional Problems *
If yes to emotional problems, please explain.
Your answer
Epilepsy *
Fainting *
Headaches *
If yes to headaches, what type (example - migraines)?
Your answer
Heart Problems *
Kidney Problems *
Hearing Problems *
High Blood Pressure *
Knee Problems *
Orthopedic Problems *
Rheumatic Fever *
Speech Problems *
Tuberculosis *
Vision Problems *
If yes to vision problems, does the student wear glasses or contacts?
Your answer
Other - please explain.
Your answer
In the last 12 months has the student had a...
Diagnosed Concussion *
If yes to a recent concussion, please explain.
Your answer
Serious Accident *
If yes to a recent serious accident, please explain.
Your answer
Serious Illness *
If yes to a recent serious illness, please explain.
Your answer
Skull Fracture *
If yes to a recent skull fracture, please explain.
Your answer
Medication
Is the student on any medication now? *
If yes to medication, please provide the specific medication name.
Your answer
If yes to medication, is there any medication which must be given at school?
* If medication must be given at school, the natural parents must have the child's doctor complete the medication form.
Privacy Policy
Roncalli High School respects the privacy of our students. All health information is kept strictly confidential in accordance with HIPAA law.
I authorize this information to be released to the appropriate school personnel.
Parent Signature
Your answer
Date
Your answer
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