Student Health History Form
Uploaded by
Tenshi Kathzka AgcaoiliStudent Health History Form
Uploaded by
Tenshi Kathzka AgcaoiliSample STUDENT HEALTH HISTORY
Name: Address: Date of Interview: Age: Phone Number: Individual providing health history: Birthdate:
History: Were there any issues during pregnancy, labor and or delivery for this child! If yes, please describe: Does this child have an ongoing health concern! #asthma, diabetes, etc$% If &yes', please describe: Does this child have any allergies! "es No If &yes', please list: (as the allergy re)uired emergency treatment! If &yes', please e*plain: Are the child+s immuni,ations up to date! Additional immuni,ations re)uired:
"es No "es No
"es
No No given! "es No No Nose Nec0
"es
Is there a history of any hospitali,ations, significant in-uries or surgery! If &yes', please describe: Are there any current medical concerns in-uries! (ead .yes .ars 1hest 1ardiovascular 3enitourinary 4usclos0eletal #include any past fractures, etc$% Does this child ta0e any medication regularly at home! 2e)uire medication at school! If &yes', please describe: Please list any additional concerns or information: Describe child+s nutritional pattern and dietary inta0e: 5ist any significant medical concerns in family: 4other 7iblings 8ther "es
/hroat 2espiratory 3astrointestinal Neurological
"es "es
No No
6ather 3randparents
Who lives with the child in his her primary household! Does child spend a significant amount of time in another household! If &yes', please describe: Who has legal custody of this child! Describe any custody arrangements: Any additional concerns or pertinent information #use bac0 as needed%: Name and /itle of Interviewer:
"es
No
Date:
