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Health History Form
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Health History
Please fill out this form completely and discuss any medical concerns with your chorister's director.
Health History
*
Asthma
Bleeding Disorder
Chicken Pox
Chronic Ear Infections
Convulsion/Seizure
Diabetes
Drugs
Hay Fever
Heart Disease
Hypertension
Measles
Mumps
Musculoskeletal
None
Other (Specify)
If 'Other' is selected, please specify below
Health History - Other
Please specify
Other Disabilities/Illnesses Not Listed Above
Allergies
*
Animals
Food
Insect stings/bites
Medicine/Drugs
Plants
Pollen
None
Other (Specify)
Allergies - Other
Please specify
Please provide details for any items selected:
Specific nature of allergic reaction
Does your chorister receive their immunizations
- None -
yes
no
Are their immunizations up to date?
- None -
yes
no
Is your chorister on a special diet?
*
Gluten Free
Vegetarian
Vegan
Lactose intolerant
Other (Specify)
None
If 'Other' is selected, please specify below
Special Diet - Other
Please specify
Are there any other health considerations we should know about?
*
Bedwetting
Braces/Retainers
Constipation
Fainting
Food Aversions
Frequent Headaches
Glasses/Contacts
Hearing Impairment
Menstruation
Nosebleeds
Sleep Walker
None
Other (Specify)
If 'Other' is selected, please specify below
Health Considerations - Other
Please specify
Are there any activity restrictions we should be aware of?
I give permission for my chorister to take the following medication(s)
Signature of parent/guardian
*
My signature above testifies that this health history is correct and my chorister has permission to engage in all planned activities, except as noted.
