Health Information Update Child's First Name Child's Last Name Upload a copy of child's latest Vision/Hearing Screening Vision/Hearing Screening Have any of the following occurred within the past year? Asthma No Yes If yes, please explain: Blood transfusion No Yes If yes, please explain: Broken bone No Yes If yes, please explain: Diabetes No Yes If yes, please explain: Head injury No Yes If yes, please explain: Heart condition No Yes If yes, please explain: Rheumatic Fever No Yes If yes, please explain: Fainting spells No Yes If yes, please explain: Seizures No Yes If yes, please explain: Surgery No Yes If yes, please explain: Vision/Hearing problem No Yes If yes, please explain: Other No Yes If yes, please explain: Allergies No Yes If yes, please explain: Medication No Yes If yes, please explain: Food No Yes If yes, please explain: Environmental No Yes If yes, please explain: Is your child on medication? Please indicate the following: Medication Name & StrengthDose/FrequencyDays TakenHomeSchool Is there any reason your child can’t participate in a full program, including physical education activities? No Yes If yes, please explain: Have there been any stressful events in your child’s life that could have an impact on his emotional wellbeing (e.g. death or serious illness, major economic changes, recent divorce/remarriage, etc.)? No Yes If yes, please explain: Has your child had the chicken pox? No Yes If yes, when: Please provide the contact information for the physician who last examined your child: Name Address Phone Parent / Legal Guardian Name