DRMS Student Medical Profile
*If necessary, use the back of this sheet to provide additional/detailed information.
Student ___________________________________ Age _____ Birthdate ______________
Address ______________________________________________________________________
Parent/Guardian (print)_________________________________________________________
Home phone ______________________ (mom) ______________________________ (dad)
Cell phone ________________________ (mom) ______________________________ (dad)
Work phone ______________________ (mom) ______________________________ (dad)
e-mail _________________________________________________________________ (who?)
e-mail_________________________________________________________________ (who?)
In case of emergency contact:
Person’s Name _______________________________________________________________
Phone Numbers: home __________________ cell ________________ work _______________
Does you child have any of the following conditions?: (please circle response)
Asthma Yes No
How is this condition managed? ___________________________________________
Anemia Yes No
Diabetes Yes No
How is this condition managed? ___________________________________________
Epilepsy Yes No If yes, please provide details.
Heart Condition Yes No If yes, please provide details.
Respiratory Illness Yes No If yes, please provide details.
Allergies Yes No
What kind(s) ____________________________________________________________
How is this condition managed?________________________________________________
________________________________________________________________________
Migraines Yes No
Will you have medication available in the office for your child? __________________________
Other(s) (use the back of this sheet if necessary) ______________________________________
Does your child take any medications? _______ If yes, please list: _________________________
Does your child have limitations on exercise / physical activity? If yes, please explain