STUDENT HEALTH HISTORY UPDATE 21/22

STUDENT HEALTH HISTORY UPDATE

2021/2022
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

Month Day Year
Signature *

Clear
Student's Name *

First Name Last Name
DOB *

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

ADD/ADHD Asthma Bone/Spine Heart Speech Allergies Bowel/Bladder Infections Surgery Asthma Diabetes Kidney Vision Blood Disorder Emotional Physical Disability Body Piercing/Tattoo Hearing Seizures Other
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 arrangements No
8. Has your child ever been examined by an eye doctor? *

Yes (answer below) No
Date of exam?

Month Day Year
Glasses provided? *

Yes No
If your child wears glasses or contact lenses, when was the prescription last changed?

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

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

Month Day Year
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 nurse No
Should be Empty: