Name of Child _______________________________________________
Address __________________________________________ Telephone# _____________________________
Date of Birth_______________________ Place of Birth _____________________________________
Father’s Name _________________________ Mother’s Name___________________________________
Legal Guardian: Both Parents Father Mother Other (Name)
If divorced or separated, which residence is child living
Father’s Occupation______________________ Mother’s Occupation_________________________
Blue CT State Health Form with Immunizations Yes No (if entering gr. K, 7, or 11)
If No: Date of M.D. appointment: ___________________
Family Doctor/Primary Care Provider _________________
Family Dentist _________________
Name of Health Insurance Coverage __________________
If your child is uninsured, would you like information regarding
State Husky Plan Yes No
School Accident Insurance Yes No
Has your child had any of the following? (Please describe)
Accidents (Date and description) ________________________________
Allergies:
Food Yes No (if yes, describe reaction and treatment)
Insect Stings Yes No (if yes, describe reaction and treatment)
Medication Yes No (if yes, describe reaction and treatment)
Environmental Yes No (if yes, describe reaction and treatment)
Asthma Yes No (if yes, list what triggers it)
Symptoms ______________________________________________________________
Inhaler/medications? Yes No (if yes, list name)
Seizures Yes No (If yes, on any medication?)
Congenital Anomaly Yes No
Diabetes Yes No
Ear Infections Yes No
Ear Tubes Yes No
Encephalitis Yes No
Rheumatic Fever Yes No
Head Injury Yes No
Scarlet Fever Yes No
Heart Disease Yes No
Scoliosis Yes No
Hernia Yes No
Tonsillitis Yes No
Kidney Disease Yes No
Strep Infection Yes No
Lead Poisoning Yes No
Tuberculosis Yes No
Meningitis Yes No
Whooping Cough Yes No
Operations (include date) Yes No
Other ______________________________________________________
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Please describe any physical disability or serious illness
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Is your child receiving medication? Yes No (If yes, please list)
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Additional information that may be pertinent to your child’s well being?
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Parent/Legal Guardian Signature ________________________________ Date _____________