Mary Help of Christians Academy

Skip to main content
Mobile Menu
More Info

Loading...

Editing previous response:

Please fix the highlighted areas below before submitting.

Family Medical History

All forms are to be completed by the parent/guardian. Required fields marked *

Have you or any member of your family had any of the following? Please check all that apply.*
Answer Required
Yes
No
Tuberculosis
Diabetes
Heart Disease/Murmur
Hypertension
Kidney Disease
Asthma/Hay Fever
Epilepsy/Convulsions

Immediate Family History

Mother

Father

Sibling

Sibling

Sibling

Sibling

Personal History

Has the student ever had any of the following?*
Answer Required
Yes
No
Measles
Mumps
Rubella
Chicken Pox
Strep Throat
Scarlet Fever
Mononucleosis
Bond/Joint Disease/Injury
Scoliosis
Surgery
Stomach Intestinal Problem(s)
Recurrent Anxiety
Undue Nervousness
Normal Eating Habits
Hearing Problem
Vision Problem
Abnormal Menstruation
Recent Weight Gain
Recent Weight Loss
Recurrent Headaches/Migraines
Asthma
Allergies (Specify below)
Does the student take medication on a regular basis?*
Answer Required
Documentation:
Please upload any supporting medical records as needed.
Answer Required
or drag it here.
Confirmation Email