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Helbredsoplysninger // Health Report

Om eleven // About the student
Full name
CPR number
Grade level
If member of National Health Insurance, please state group number
Forsørger // Guardian
Full name
Private phone number or cell phone
Work phone
Vaccinationer // Vaccinations
Please state year of vaccine, if vaccinated
Diphtheria, tetanus, whooping cough and polio
Measles, mumps and german measles
Meningitis, pneumonia, etc.
Cervical cancer, genital warter, etc.
Other vaccinations
Nuværende eller tidligere behandling // Current or privious treatment
Does the student take any medication?

Please state allergies if any
Does the student currently suffer or has he/she priviously suffered from any medical conditions?

Has the student been or is currently undergoing treatment for psychological conditions such as eating deisorder, self-inflicted injury behavior, depressions, etc.?

Andre helbredsmæssige hensyn // Other health issues
Concerns regarding food, physical activities, etc.?

Other health issues that the school need to be aware of?