HEALTH AND EMERGENCY INFORMATION
A. STUDENT NAME
: ___________________________________ Date of Birth:_________________________(M) (D) (Y)
Living with (if other than parent(s)): _________________________________________Grade Level _______
Family Physician: _____________________________________ Office Phone:________________________
Hospital of Preference: ( ) Hospital de Liberia ( ) Hospital de Nicoya ( ) Clínica Los Ángeles
B. HEALTH INFORMATION
Allergy ( ) YES ( ) NO
Medicines / Food / Insects: __________________________________________________________________
Life Threatening Allergies: __________________________________________________________________
C. STUDENT’S MEDICAL HISTORY:
( ) Asthma ( ) Thyroid
( ) Migraines / Headaches ( ) Cholitis or chronic stomach pain
( ) Diabetes ( ) Behavior Disorder (ADD, ADHD)
( ) Heart problem ( ) High blood pressure
( ) Seizures ( ) Other medical problems
Comment (any items checked): ______________________________________________________________
D. MEDICATION
Medicine taken at home every day: ___________________________________________________________
Medicine taken at school every day: ___________________________________________________________
If your child experiences fever and/or pain while at school, please indicate if the school is authorized to
administer mild medication:
( ) YES ( ) NO If yes, check the type below:
( ) Tylenol / Panadol ( ) Ibuprofen / Dorival ( ) PeptoBismol / Tums
( ) Panadol Cold ( ) Otosedan Ear Drops ( ) Other: __________________
E. EMERGENCY CONTACTS
: Please provide us with the names of two persons whom we should contact inyour absence:
Contact 1 Contact 2
Name: ______________________________ ______________________________
Relation: ______________________________ ______________________________
Home Phone: ______________________________ ______________________________
Work Phone: ______________________________ ______________________________
Cellular Phone: ______________________________ ______________________________
Country Day School
2006