St. John the Baptist Catholic School

Health Questionnaire

(Parent/Guardian need to complete)

Student Date of Birth

Address

Phone Number Grade Room #

Father’s Name Mother’s Name

Student lives with

Disease/Condition Yes No Disease/Condition Yes No

(List mo./yr) (List mo./yr)

Asthma Mumps

Diabetes Rheumatic Fever

Seizures Rubella

Chickenpox Scarlet Fever

Measles Other

Has your child had an infectious/communicable disease other than those listed above? Please explain giving relevant dates

Please list any of the following with the month/year

Operations

Illnesses (eye, ear, heart, stomach, kidney)

Severe Injuries (head injury, fractures, etc.)

Is there any other information about your child’s health status that you think the school should know which may be relevant to your child’s health and safety or the health and safety of others in the school environment?

Please list any condition that should be considered in planning your child’s school day

Allergies/Reactions

Physician Name Phone #

Dentist Name Phone #

To the best of my knowledge the above information is complete and accurate. I acknowledge that I have a continuing obligation to inform the school of any changes in my child’s health status that are relevant to the information requested by this form.

Parent Signature Date