Health Information

	Is the child having any of the following?	Yes	No
	Allergies or reactions (food, medication, bee stings, etc.)
	Hay Fever, Asthma, wheezing, shortness of breath
	Frequent skin rashes
	Convulsions / Seizures
	Heart Trouble
	Diabetes
	Hearing problems
	Vision problems
	Speech problems
	Other Health Issue(s) / Physical Limitations / Restrictions (Explain)
	Is the school authorized to give the student analgesic like acetaminophen (Tynenol, Panadol)?