CKCA Student Medical

Health History

Student First & Last Name *

Vision/Hearing Problems: *

No glasses or contacts needed

Wears glasses/contacts

If wears glasses/contacts:

For board work

for reading/computer

All the time

Date of last eye exam *

Hearing: *

No hearing issues

Wears hearing aid(s)

Other Other

Mark the medical conditions that apply:

	check all that apply
Current Asthma (does student use inhaler or on daily medication)	check all that apply	check all that apply
Diabetes (is student insulin dependent)	check all that apply	check all that apply
Current Seizures (is student on medication)	check all that apply	check all that apply
Behavior Problems	check all that apply	check all that apply
Movement Limitations	check all that apply	check all that apply
Severe Allergies (Food, Latex, Medication, Insects, Environmental, Other)	check all that apply	check all that apply
Other	check all that apply	check all that apply

Please explain if any of the above were selected or list any other medically-relevant issue

If any recent illness, hospitalization, or surgery, please provide date(s) and description(s):

List any medical conditions which might require care or accommodation at school (please describe):