NOTE: You must also submit a copy of the student’s immunization records to complete Registration Requirement #2.
Pt. 2: Please PRINT this portion of the form as it is to be completed by a health professional.
Student Name: ____________________________
Student DOB: __________________
Student Medical Information
Height: ________ Weight: ________ Blood pressure: ________
Vision: (R) ______ (L) ______ Hearing: (R) ______ (L) ______
Any head injuries/dizziness? ___ No Yes, explain: __________________________
Any fractures? ___ No Yes, date: ____________________________
Any allergies? ___ No Yes, list: _____________________________
Any lung disease? ___ No Yes ___
Any heart disease? ___ No Yes ___
Previous hospitalization? ___ No Yes, date: ____________________________
Currently taking medication? ___ No Yes, name of medication(s): ______________ _____________________________________________________________________
Handicapping conditions? (Please explain and specify.) _________________________ _____________________________________________________________________