Form 5, Student Medical Information Form



School Name

School Address

School Phone Number

STUDENT MEDICAL INFORMATION (optional as needed)

PLEASE PRINT

Student Name: _____________________________________________________________________________________

Emergency Contact: _________________________________________________________________________________

Relationship:______________ Phone numbers:____________________________________________________________

Physician’s name and phone number:___________________________________________________________________

Medications:

|NAME |DOSE |

| | |

| | |

| | |

| | |

Allergies:___________________________________________________________________________________________

Physical Restrictions:_________________________________________________________________________________

History: Yes No

Heart Condition

Diabetes

Asthma

Epilepsy

Other conditions:____________________________________________________________________________________

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