West frankfort elementary school

WEST FRANKFORT ELEMENTARY SCHOOL

HEALTH AND IMMUNIZATION RECORD

Child’s Last Name:______________________________First:________________________Middle:_________________

Address:__________________________________________________________________________________________

Home Telephone Number:________________________________________________________

Birthdate:___________________________ Age:____________ Copy of Birth Certificate Attached: Y or N

Parent(s)/Guardian(s) with whom the child lives with:______________________________________________________

Father’s Names (First/Last):___________________________________________________________________________

Place of Employment:________________________________________________________________________________

Work Number:___________________________________ Cell Phone Number:_________________________________

Mother’s Name (First and Maiden Name):________________________________________________________________

Place of Employment:________________________________________________________________________________

Work Number:___________________________________ Cell Phone Number:_________________________________

Emergency Contact Person:___________________________________________________________________________

Phone Number(s):___________________________________________________________________________________

Emergency Contact Person:___________________________________________________________________________

Phone Number (s):__________________________________________________________________________________

Copy of Immunization Record Attached: Y or N Complete: Y or N Incomplete: Y or N

Copy of Physical Exam Attached: Y or N

Has your child ever had any of the following:

NO YES IF YES, NO YES IF YES,

WHAT YEAR WHAT YEAR

_____ _____ __________ RUBELLA _____ _____ __________ FREQUENT COLDS

_____ _____ __________ MEASLES _____ _____ __________ FREQUENT EAR INFECTIONS

_____ _____ __________ MUMPS _____ _____ __________ VISION PROBLEMS

_____ _____ __________ SCARLET FEVER _____ _____ __________ RHEUMATIC FEVER

_____ _____ __________ PNEUMONIA _____ _____ __________ DIABETES

_____ _____ __________ EPILEPSY _____ _____ __________ ASTHMA/ALLERGIES

_____ _____ __________ TUBERCULOSIS _____ _____ __________ SURGERIES(SPECIFIY)

(in family)

PLEASE NOTE BELOW ANY SERIOUS ILLNESS(ES) OTHER THAN ABOVE OR ANY OTHER INFORMATION THAT THE SCHOOL’S HEALTH OFFICE SHOULD KNOW ABOUT YOUR CHILD:__________________________

__________________________________________________________________________________________________

CHILD’S PHYSICIAN:___________________________________________ PHONE:___________________________
PARENT’S SIGNATURE:____________________________________________________________________________
DATE:________________________________________________