STUDENT HEALTH HISTORY UPDATE 22/23

STUDENT HEALTH HISTORY UPDATE

2022/2023
This information will be shared on a need to know basis with staff, administration and emergency medical staff in the case of an emergency unless you notify us otherwise.
Today's Date

MonthDayYear
Signature*

Clear
Student's Name*

First NameLast Name
DOB*

MonthDayYear
Date
Grade:*
Teacher*
1. PLEASE CHECK IF CHILD HAS HAD DIFFICULTY WITH ANY OF THE FOLLOWING. GIVE DATES AND ADDITIONAL INFORMATION UNDER COMMENTS.*

ADD/ADHDAsthmaBone/SpineHeartSpeechAllergiesBowel/BladderInfectionsSurgeryAsthmaDiabetesKidneyVisionBlood DisorderEmotionalPhysical DisabilityBody Piercing/TattooHearingSeizuresOther
Comment:
please explain other
2. Does your child have allergies to medicine, food, latex or insect bites?*

Yes (answer below)No
To What?
What Happens?
Treatment(s)?
3. Has your child had any illnesses since school last ended?*

Yes (answer below)No
a. Types of illness with date(s)?
4. Has your child had surgery since school last ended?*

Yes (answer below)No
a. Types of surgery with date(s)?
5. Has your child received any immunizations since school last ended?*

Yes (answer below)No
a. Types of immunization with date(s)?
6. Is your child being treated or evaluated for any health conditions?*

Yes (answer below)No
List condition(s):*
7. Is your child on any medication or treatment?*

Yes (answer below)No
Name medication and or treatment(s):
7a. Does your child need medicine during school hours?*

Yes, if so, please see the school nurse to make arrangementsNo
8. Has your child ever been examined by an eye doctor?*

Yes (answer below)No
Date of exam?

MonthDayYear
Glasses provided?*

YesNo
If your child wears glasses or contact lenses, when was the prescription last changed?

MonthDayYear
9. What is the name of your child's dentist?*
a. What is the date of his/her last dental exam?

MonthDayYear
10. What is the name of your child’s primary healthcare provider?*
a. What is the date of his/her last physical exam?

MonthDayYear
11. Has your child experienced any major life events, such as a recent move, death, separation, divorce, etc. since the end of last school year?*

Yes *If yes, please contact your school nurse or school counselor.No
12. Have you, your child or anyone in your household tested positive for COVID-19?*

Yes *If yes, please contact your school nurseNo
Should be Empty: