Plainfield Community ConsolidatedSchool District 202We prepare learners for the future.

Administration Center15732 Howard StreetPlainfield, IL 60544

(815) 577-4000 – telephone(815) 436-7824 – main fax

Web: www.psd202.orgStudent Health History School Year 2018-2019

Student Name: Grade: School:

Sex: Male Female Birth Date: Phone Number:

Doctor’s Name:

(if you indicate YES for any category, please explain)

# Concern Yes or No Explanation & Comments

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

Allergies

*Uses EpiPen

Asthma

*Uses Inhaler

*Uses Inhaler at School

Blood Disorders

Daily Medications

*Names of Medication(s)

School Medications REQUIREMedical Authorization Form

Diabetes

Ear / Hearing Problems

Glasses / Contacts

Eye / Vision Problems

Heart Problems

Hospitalizations

Mental Health Concerns

Neurological Problems

Physical Restrictions

Seizures

Serious Injuries

Surgery

Other

At home

At school

Last eye exam:

Age:

Age:

Age:

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Rarely Once daily More than once daily For Sports

I release this information to be shared with appropriate school and emergency personnel for health and educational purposes.

Parent / Guardian Signature Date

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