Name

First Name

Last Name

Date of Birth

MM

DD

YYYY

Ibuprofen - Form

Select all forms your son can receive.

Pill

Liquid

Chewable

None

Tylenol - Form

Select all forms your son can receive.

Pill

Liquid

Chewable

None

Benadryl - Form

Select all forms your son can receive.

Pill

Liquid

Chewable

None

Imodium - Form

Select all forms your son can receive.

Pill

Liquid

None

Health History

Please CHECK all boxes that apply. Then provide extra necessary information in the text box below.

Scarlet fever

Appendectomy

Head injury

Seizures

Heart murmurs

Hepatitis

GI/stomach problems

Frequent headaches

Wears glasses/contacts

Chicken pox

Tonsillectomy

Asthma

Diabetes

ADD/ADHD

Kidney/bladder problems

Cardiac problems

Immunizations up-to-date

Wears braces/retainer

Other

Emergency Contact 1 *

First Name

Last Name

Emergency Contact 1 - Phone *

(###)

###

####

Emergency Contact 2 *

First Name

Last Name

Emergency Contact 2 - Phone *

(###)

###

####