CKCA Student Medical

Health History

Vision/Hearing Problems: *
If wears glasses/contacts:
Hearing: *
Mark the medical conditions that apply:
 check all that apply
Current Asthma (does student use inhaler or on daily medication)
Diabetes (is student insulin dependent)
Current Seizures (is student on medication)
Behavior Problems
Movement Limitations
Severe Allergies (Food, Latex, Medication, Insects, Environmental, Other)
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