GENERAL INFORMATION

Queen of Peace School

2550 Millville Ave., Hamilton, Oh. 45013

Childs Name Sex Date of Birth

Last First Middle

Address Phone

Father’s Name Place of Employment

Mother’s Name Place of Employment

Physician Dentist

DISEASE AND ILLNESS HISTORY

Give dates if your child had had any of these diseases:

Chickenpox Whooping Cough Measles (Rubeola)

German Measles (Rubella) Mumps Diphtheria

Poliomyelitis Rheumatic Fever Diabetes

Epilepsy or Convulsions Tuberculosis

Allergies, Eczema, Hay Fever, Asthma, Foods

Frequent sore throats Infected Ears

Headaches Injuries (types and dates)

Hospitalizations (reasons, dates)

Operations (specify)

Other Illness

Emotional and Behavior History (note special problems and age of occurrences)

MEDICAL EXAMINATION: Medical examination form should be completed by your physician.

Date Signature of Parent

(Use back side of form for additional information.)