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Sparta Township Schools Health History Name of child _______________________ School ____________ Grade_______ Disease History: (include date if known) Allergies Anemia Asthma Bedwetting Bowel problems Chicken pox Congenital defects Convulsive disease Dental Problems Other Diabetes Drug sensitivities Ear problems Eye problems Headaches Heart disease Hepatitis High fevers Mononucleosis Neuro. disease Pneumonia Rheumatic fever Skin problems Speech problems Stomach problems Strep Infections Unconsciousness Urinary problems Operations or injuries____________________________________________________________ Is your child currently taking any medication? ________________________________________ If yes, please describe____________________________________________________________ Responses to the following items are optional Pregnancy and Birth Was this pregnancy unusual in any way? __________________________________________ Were there any complications during the birth of this child? ____________________________ Explain: _____________________________________________________________________ Early Childhood Were there any problems with feeding or sleep problems? _____________________________ Explain: _____________________________________________________________________ At what age did your child? Sit____________ Stand ____________ Walk _____________ Speak words _________________ Speak sentences ___________ Toilet train __________________ Feed self ________________ Family Health History (Circle those that apply) Has any relative had: Allergies, Asthma, Drug or alcohol addiction, Rheumatic fever, Heart Disease, Diabetes, Tuberculosis, Convulsive disorder, Mental illness, Cancer? 98
