9800 SE 92nd Avenue • Happy Valley • OR • 97086 • (503) 788-7000
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Health History Downloadable Form
File Size:
383 kb
File Type:
pdf
Download File
Health History Form
Good from Sept 1, 2019 to Aug 31, 2020
*
Indicates required field
Today's Date (MM/DD/YYYY):
*
00/00/0000
Student Information
Name:
*
First
Last
Choose One:
*
Male
Female
Date of Birth:
*
Student Email:
*
If not member at BSLC, name(s) of connection to BSLC:
*
Mailing Address:
*
Line 1
Line 2
City
State
Zip Code
Country
School:
*
Grade:
*
Student Home Phone:
*
Student Cell Phone:
*
Student Cell Carrier:
*
Can receive text message reminders about upcoming events, deadlines, and schedule changes
*
Yes
No
Parent/Guardian 1
Parent 1 Name:
*
First
Last
Parent 1 Relationship:
*
Parent 1 Cell Phone:
*
Parent 1 Email:
*
Parent 1 Home Phone:
*
Parent/Guardian 2
Parent 2 Name:
*
First
Last
Parent 2 Relationship:
*
Parent 2 Cell Phone:
*
Parent 2 Email:
*
Parent 2 Home Phone:
*
in case of emergency
Emergency Contact (Not Parent/Guardian 1 or 2):
*
First
Last
Emerg. Relationship:
*
Emerg. Phone Number:
*
Student health
Physician Name:
*
Health Insurance Info:
*
List All Drug Allergies:
*
List All Food Allergies:
*
List all Environmental Allergies:
*
Physician Office:
*
History of:
*
Heart Disease
Epilepsy
Convulsions
Diabetes
Asthma
Rheumatic Fever
Smoking
Has Been Vaccinated For:
*
Mumps
Measles
German Measles
Has Had:
*
Measles
German Measles
Chicken Pox
Hepatitus
Wears:
*
Glasses
Contacts
Date of Tetanus Booster:
*
List all medications:
*
Additional Comments:
*
Parent / Guardian E-Signature (Full name & DOB):
*
Student will be responsible for own medication:
*
Yes
No
Student may be given Tylenol/ibuprofen for headaches and/or minor injuries:
*
Yes
No
This health history is correct as far as I understand, and the person herein described, is free of potential health problems which might restrict his or her participation (except as noted). In the event I cannot be reached in an emergency, I hereby give permission to the physician, hospital, clinic selected by the youth leaders to treat, hospitalize, secure proper anesthesia, injections or surgery.
Submit Health History
