Health History
Parent name
Your answer
Student Name
Your answer
If your child suffers from any of the following conditions, please check the appropriate box.
If you checked any boxes in the above question, please explain below.
Your answer
Medications Currently Taking/Using – All Prescription and Non-Prescription ORAL medication(s) and Prescription EXTERNAL medication(s), such as, inhaler, anticonvulsive, antihistamine, antifungal, acne, insulin, Ritalin, etc. Giving medication name, date treatment prescribed and instruction(s):
Your answer
Recent Surgery/Procedures/Illness (within 1 year)
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Past Surgery/Procedures/Illnesses (greater than 1 year ago) that may be significant to extensive exercise or important to note in an emergency):
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Is child under any medical treatment at present other than medications already listed: If yes, explain.
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Is there anything else that should be called to the attention of the Band Director and staff?
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Student's Physician Name:
Your answer
Physician's Phone Number
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