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General Health Questionnaire

"*" indicates required fields

Step 1 of 3

The following information is needed for school records. Please be as accurate as possible. Do not leave spaces blank—draw a line or write N/A in spaces that do not relate to your child. Thank you.
Student's Full Name*
Name of Parent(s)/Guardian(s)*

Immunizations and Date Received

DTP (Diphtheria, Tetanus, and Whooping Cough Vaccination)*
DTP 1st Vaccine Date
DTP 2nd Vaccine Date
DTP 3rd Vaccine Date
DTP 4th Vaccine Date
DTP 5th Vaccine Date
DTP 6th Vaccine Date
Polio Vaccination Dates*
Polio 1st Vaccine
Polio 2nd Vaccine
Polio 3rd Vaccine
Polio 4th Vaccine
MMR (Measles, Mumps, and Rubella)*
MMR 1st
MMR 2nd
Hepatitis A Vaccine Dates*
Hepatitis A
Hepatitis A 2nd
Hepatitis B Vaccine Dates*
Hepatitis B 1st
Hepatitis B 2nd
Hepatitis B 3rd
Varicella Vaccine Dates*
Varicella 1st
Varicella 2nd
My child has *NOT* received immunizations, and I have signed and attached a Certificate of Exemption.
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