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EMERGENCY HEALTH RECORD

Name :

______________________________

I agree to provide the following health information :

Please print

_________________________________________

________________________________________ Date

Student Signature

PROGRAM:

GROUP:

START DATE:

__________

______________

__________________

E-mail: ________________________________________

Name of contact person in case of an emergency: _____________________________________

Relationship: ________________________

Telephone: (

) ______________________

STUDENT HEALTH RECORD :

2012-2013

HEALTH PROBLEMS Vision Hearing Diabetes Epilepsy Cardio-Vascular disorders Neurolegical disorders Asthma Gastrointestinal problems Blood disorders Other(s) specify:

YES

NO

MEDICATION YES NO

RECOMMENDATION

  • peanuts

  • feathers eggs antibiotic

  • insect bites

  • others

Specify:

_________________________________________________

ALLERGY(IES)

Type of reaction:

_________________________________________

Medication used:

  • Epipen

  • Cortisone

  • Others :

Specify: ____________________________________________________

20

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