Westhill high school instrumental music program



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WESTHILL HIGH SCHOOL INSTRUMENTAL MUSIC PROGRAM

Health History Form 2017-18
Student Name: ____________________________________________________________

Parent Signature: _________________________________ Date: ______________, 2017





Yes

No

Please Note: All information provided by you will be kept in strict confidence

1







Do you have any concerns about your child’s general health (eating & sleeping habits, weight, teeth, etc.)?

2







Does your child have any other specific illness or problem?

3







Does your child have any allergies (food, insects, medications, etc.)?

4







Does your child take any medication (daily or occasionally)?

5







Does your child have any problem with hearing, vision, or speech (glasses, contacts, ear tubes, hearing aids)?

6







Has your child had any hospitalizations, operations, or major illness (specify problem)?

7







Has your child had any significant injury or accident (specify problem)?

8







Would you like to discuss anything about your child’s health?


Place a check mark next to the medical condition listed below that applies to your child’s medical history

____ Anemia




____ Pneumonia




CURRENT MEDICATION

____ Arthritis




____ Poliomyelitis







____ Asthma




____ Psychological Disorder







____ Bleeding Disorder




____ Rheumatic Fever







____ Bronchitis




____ Scarlet Fever







____ Chicken Pox




____ Sinusitis







____ Convulsions/Neurological Disorders




____ Sleep Walking







____ Diabetes




____ Thyroid Condition







____ Eating Disorders




____ Tuberculosis







____ Epilepsy




____ Tumors







____ Eye Ailments













____ Fainting




Visual







____ Frequent Colds




____ Eye Glasses







____ German Measles




____ Contact Lenses







____ GI/ Stomach Problems













____ Headaches




Allergies







____ Heart Ailments




____ Hay Fever







____ Kidney Ailments




____ Insect Stings







____ Measles




____ Penicillin







____ Mononucleosis




____ Other







____ Motion Sickness (Vertigo)




____ Other







____ Mumps













____ Orthopedic Fractures
















Primary Care Physician’s Name:

Office Phone:

Office Address:




Please photocopy the front and back of student’s insurance card onto the back of this form or attach as a separate page


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