| PARENT INFORMATION |
| Parent Name: |
John Moelker |
Parent DOB: |
11/1/1971 |
| Parent E-mail: |
lexasparent@yahoo.com |
| Parent Day Phone: |
416-333-9999 |
Parent Evening Phone: |
416-555-5555 |
| Parent 2 Name: |
Liz Moelker |
Parent 2 DOB: |
6/12/1969 |
| Parent 2 Day Phone: |
416-555-7444 |
Parent 2 Evening Phone: |
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| STUDENT INFORMATION |
| Student Name: |
Mrs. Lexa Moelker |
Student DOB: |
4/1/2000 |
| Student Gender: |
F |
Student OEN: |
123445566 |
| Physician Name: |
Dr. James Smith |
| Physician Phone: |
416-514-8888 |
| Physician Address: |
123 Queen Street North, Toronto |
| Student Address: |
345 Erinbrook Drive, Toronto, ON |
| Contact E-mail: |
lexa@yahoo.com |
| School Board: |
Bluewater District School Board |
| School: |
Bluewater Elementary |
| Current Grade: |
2 |
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| STUDENT IDENTIFICATION AND
NOTES |
| Student Race: |
White |
| Primary Language: |
ENGLISH |
| Secondary Language: |
FRENCH |
| Student Height: |
4' 2" |
Student Weight: |
40 lbs |
| Student Eye Color: |
Green |
Student Blood Type: |
B+ |
| Parent Marital Status: |
Never Married/Single |
# of Children in this school: |
1 |
| Notes/Comments: |
Allergic to peanut butter. |
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| EMERGENCY CONTACT DETAILS |
| Emergency Contact Name: |
John Moelker |
| Emergency Contact Address 1: |
57 Rushbrook Drive |
| Emergency Contact Address 2: |
Apt 222-B |
Emergency Contact City: |
Kitchener |
| Emergency Contact Province: |
Ontario |
Emergency Contact Country: |
Canada |
| Emergency Contact Postal Code: |
N2E 5D8 |
Emergency Contact Day Phone: |
416-111-1111 |
| Emergency Contact Evening Phone: |
416-222-2222 |
Emergency Contact Cell Phone: |
416-888-8777 |
| Emergency Contact Relationship to Student: |
Uncle |
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| INSURANCE INFORMATION |
| Insurance Plan Name: |
Ontario Health Insurance Plan (OHIP) |
| Insurance Plan Number: |
5555488515 |
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| CARE GIVER DETAILS |
| Caregiver Name: |
Jane Doe |
| Caregiver Role: |
Person legally responsible |
| Caregiver Day Phone: |
416-222-2222 |
Caregiver Evening Phone: |
416-555-1222 |
| Caregiver Cell Phone: |
416-333-3333 |
Caregiver Relationship to Student: |
Aunt |
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| Allergy DETAILS |
| Life Threatening Food Allergens: reaction is immediate to less than 1 hour |
| Sesame seeds | | Shellfish (Shrimp, lobster, others) | | Tree Nuts (such as almond, pecan, walnut, hazel, Brazil, cashew) | | Wheat |
| Other Life Threatening Allergens causing Anaphylaxis: reaction is immediate to less than 1 hour |
| Idiopathic | | Insect stings (e.g., wasp, bee, hornet, yellow jacket, fire ant) | | Latex | | Sulfite |
| Food Sensitivity: not life threatening, reaction in more than 1 hour |
| Sulfite | | Wine, Beer |
| Contact Allergy: not life threatening |
| Betadine | | Latex/ rubber | | Topical Antibiotics (Neosporin, Polysporin) |
| Airborne Allergens: |
| Cockroach | | Weed Pollen |
| Drug Allergy: reaction is immediate or delayed: |
| Beta blocker medications | | Insulin | | Sulfa drugs |
| All Other Allergies: |
| Blue Dye | | test2 | | TEST |
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| SURGERIES AND PROCEDURES DETAILS |
| Colonoscopy | | Gall Bladder Removal (Cholecsystectomy) | | Vasectomy (Male Sterilization) | | test's hehe | | second testing this thing ok |
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| MEDICATION DETAILS |
| Albuterol | | Norvasc | | Zocor | | TEST'S | | TEST2 |
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| IMMUNIZATIONS DETAILS |
| Anthrax | | Mumps | | Tetanus and Diphtheria booster(Td) | | Yellow Fever | | FVFBV | | TEST444 |
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| MEDICAL HISTORY DETAILS |
| Abdominal Pain (Colic in infants) | | Abnormal PAP | | Birthmarks | | Breast Cancer | | Prostate Problems | | Roseola (baby measles) | | Tubal Pregnancy | | Uterine Cancer | | Warts |
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