ABOUT OUR SCHOOL
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FAQ’s
FOR PARENTS
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Out-Of-District Enrollment
Census
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ABOUT OUR SCHOOL
Mission
Curriculum
Faculty & Staff
Our History
FAQ’s
FOR PARENTS
Policies & Plans
Parent & Community Groups
Student Forms
Out-Of-District Enrollment
Census
CALENDAR
PHOTOS & PRESS
MEETINGS & MINUTES
School Board Meetings
Shared Decision Making
Committee Agendas
Additional Documents
DISTRICT & BOARD
Board of Trustees
District Budget
School Statistics
NYS School Report Cards
CONTACT US
Test Form 2
Home
Test Form 2
Medical History
Patient's information
Name
*
Name
First
First
Middle
Middle
Last
Last
Date of Birth
*
Gender
*
Male
Female
N/A
Phone Number
*
Email Address
*
Emergency Contact
Emergency Contact Name
*
Emergency Contact Name
First
First
Last
Last
Relationship to Patient
*
Mother
Father
Guardian
Sister/Brother
Partner
Emergency Contact Number
*
Medical History
Check the symptoms that you' re currently experiencing:
Allergy
Cardiovascular
Chest Pain
Diabetes
Ear / Nose / Throat
Eye
Fever
Gastrointestinal
Genitourinary
Hematological
Lymphatic
Musculoskeletal
Neurological
Psychiatric
Respiratory
Weight Gain
Weight Loss
Other
Other
Are you currently taking any medications?
*
No
Yes
Yes
Do you have any known medical allergies?
*
No
Yes
Yes
Are you currently under medical treatment?
*
No
Yes
Yes
Have you been admitted to hospital or had surgery within the last 2 years?
*
No
Yes
Do you use any kind of tobacco or have you ever used them?
*
No
Yes
Yes
Do you use any kind of illegal drugs or have you ever used them?
*
No
Yes
Yes
How often do you consume alcohol?
*
Daily
Weekly
Monthly
Occasionally
Never
Family History
Check the conditions that apply to you or any member of your immediate family:
Asthma
Cancer
Cardiac Disease
Diabetes
Epilepsy
Hypertension
Lung Problems
Psychiatric Disorder
Seizure Disorder
Stroke
Other
Other
If you are human, leave this field blank.
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Sagaponack School
ABOUT OUR SCHOOL
Mission
Curriculum
Faculty & Staff
Our History
FAQ’s
FOR PARENTS
Policies & Plans
Parent & Community Groups
Student Forms
Out-Of-District Enrollment
Census
CALENDAR
PHOTOS & PRESS
MEETINGS & MINUTES
School Board Meetings
Shared Decision Making
Committee Agendas
Additional Documents
DISTRICT & BOARD
Board of Trustees
District Budget
School Statistics
NYS School Report Cards
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