STUDENT HEALTH RECORD UPDATE (to be completed by Parent/Guardian)
Student Name ___________________________________________________________________
First
Health Number_________________________ Expiry Date_____________
In Canada Only
Parent(s)
Gender M
Last
Date of Birth _____/______/_________
mm-yyyy
Guardian _________________________________________
First
F
mm-dd-yyyy
______________________________________________
Last
First
Last
Home Address ________________________________________________________________________________________________
Street
Province/State/Country
Zip Code/Postal Code
Phone _________________ Mother _________________ _________________ Father _________________ __________________
Home
Cell
Work
Cell
Work
*Emergency Contact _____________________________________ ____________________________ ________________________
Name
Phone (daytime school hours)
Current Grade 9 10 11 12 (please circle one)
School Year _______/_______
Please answer the following questions:
YES
NO
If “Yes” please indicate with the corresponding
number which question and specify details below
1. Is there any new conditions for which you have
been treated for within the last year?(12) months
2. Have you been treated recently in an Emergency
Room? Within the last year (12) months
3. Are there any health conditions that have
been resolved? E.g. : Allergies, Physical, Mental
4. Do you suffer from allergies to any Food,
Medication, Animals, Dust, Pollen, Mold or
Plant? *Please give a description of the allergic reaction*
5. Do You Carry an EPI-PEN?
**Please complete side 2**
6. Are you Asthmatic?
Relationship to Student
Severe □ or Mild □
** (If SEVERE Asthma or ANAPHYLAXIS REACTIONS,
You MUST complete Emergency Protocol Form) **
History (to be completed by Parent/Guardian)
** = please complete Emergency Protocol Form
Check yes or no, and write the year when your child was diagnosed if possible
Yes
No
Year
Yes
Bleeding Disorder **
Bruise Easily
Diabetes **
Epilepsy **
Eye Disorders
Hearing Disorders
Heart Problems**
No
Year
Stomach Problems
Migraines/ Headaches
Learning Disorders
Seizures **
Visual Disturbances
Other Diseases
Previous Surgeries
Details of History (Provide details below for any items marked “Yes”)
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
Yes
No
Year
Anxiety
Depression
ADD
ADHD
Schizophrenia
Phobias
Other
Please give details:
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
Medication(s): Yes (please list) No
__________________________________________________________
__________________________________________________________
Previous Injuries (Sprains, Strains, Fractures, Torn Muscles, Ligament Injuries, Dislocation)
Check Yes or No, and write the year when your child was diagnosed if possible
Indicate right or left
Abdominal (stomach)
Chest/Ribs
Concussion
Face Injuries: Eye/Ear/Nose
Hip
Knee/Ankle/Foot
Yes
No
Year
Indicate right or left
Yes
Pelvis
Shoulder/Upper Arm/Elbow
Skull: Fracture
Spine: Neck/Lower Back
Upper Leg/Lower Leg
Wrist/Hand
No
Year
Description (s) of Previous Injuries
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Please describe any other relevant conditions that may limit your child’s full participation in activities.
______________________________________________________________________________________________
______________________________________________________________________________________________
(It is the college policy to contact the individuals whose names appear on this document at the earliest opportunity in
the event of a serious illness or injury. In the event of an Emergency, the Ambulance will be notified.)
Signature _____________________________ Relationship_______________
To be returned to: Luther College High School
1500 Royal St., Regina SK S4T 5A5
Fax: (306) 359-6962 Tel: (306) 791-9150
Date________/_____/20____
Month
Day
**Records will be kept on file by School Nurse**