Been worried, sad, upset, or angry much of the time? 39. Ever had a hit or blow to the head that caused confusion, prolonged headache, or memory problems?ģ8. Had a history of being born without or is missing a kidney, an eye, a testicle (males), spleen, or any other organ?Ĩ.
Any ongoing medical conditions? If so, please identify: Asthma Anemia Diabetes Infection Other_Ĥ. Yes (If yes, list specific allergy and reaction.) PollensĬomplete the following section with a check mark in the YES or NO column circle questions you do not know the answer to.
Medicines and Allergies: Please list all prescription and over-the-counter medicines and supplements (herbal/nutritional) the student is currently taking: _ _ Does the student have any allergies? Take completed form toīureau of Community Health Systems Division of School Health
Complete page one of this form before student’s exam.
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