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! ! !! STUDENT HEALTH HISTORY (TO BE COMPLETED BY PARENT) STUDENT ______________________________________________________ GRADE _________ HOMEROOM _________ Sex: ___ Male ___Female Date of birth ______/_________/_______ Please complete this form and return it to school as soon as possible. If there are any future changes in your child’s health status, please call Peggy Brockmeier, RN or send a note to school. Check all health conditions your child may have. □ □ ! ADD / ADHD ALLERGIES or reactions to: (Please explain) Medication(s) __________________________________ Migraines? ___ YES _____________________________________________ BLADDER PROBLEMS (Please explain) _____________________________________________ BOWEL PROBLEMS (Please explain) _____________________________________________ DEVELOPMENTAL DELAY (Please explain) _____________________________________________ ____________________________________________ EAR INFECTIONS (frequently after age of 3) SIGNIFICANT INJURY (Please explain) _______________________________________ Approximate date or age of last infection ___________ SEIZURES / EPILEPSY □ Currently under the care of ENT? ___ YES __ NO ! ! RECENT HOSPITALIZATION/SURGERY □ Age of diagnosis _________________ Currently has PE tubes? PHYSICAL DISABILITY (Please explain) □ ______________________________________________ □ KIDNEY DISEASE (Please explain) □ ______________________________________________ DIABETES ___NO HEART CONDITION (Please explain) □ ___ NO □ HEADACHES (frequent) □ Has your child ever needed emergency treatment for asthma? □ ___ YES ___ NO ___ wears all the time or ___ for reading ___ for distance ASTHMA (Identify triggers) ______________________________________________ □ EMOTIONAL/ BEHAVIORAL CONCERNS Wears glasses/contacts? ______________________________________________ □ □ EYE PROBLEMS (Please explain) □ ____________________________________________ Plant / Animal / Environmental ____________________ ___ YES EATING DISORDER ! Food(s) _______________________________________ □ □ Date of last episode ______________________ ___ YES ___ NO _____ Wears hearing aid in right/left ear (circle) □ SPINAL CURVATURE (scoliosis, etc.) _____ Has hearing loss in right/left ear (circle) □ TICS / NERVOUS TWITCHES Has your child traveled outside the United States in the past year? _____ No _____ Yes ____________________________ (Where?) My child takes the following daily medication(s) __________________________________________________________________ My child takes the following medication(s) occasionally ____________________________________________________________ Please identify any other health information not listed above that you believe school personnel need to be aware of:______________ ___________________________________________________________________________________________________________ ! ! ! List any health conditions that require school restrictions, modifications, and/or interventions: ________________________________ ____________________________________________________________________________________________________________ This information may be shared with school personnel if it is pertinent to health and safety, educational progress and/or behavioral management plan. ! ! Parent/Guardian Signature_________________________________________________________ Date __________________ 11/2014
