2_7_22 Revised Interval Health History

Truro Central School - INTERVAL HEALTH HISTORY
Name
Date of Birth
Age
Gender

Male Female
Grade
Parent/Guardian
(Person Completing This Form)
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Date

Month Day Year
Date
Name of Primary Care Doctor:Name Office Location: Location
Office Phone Number: Phone Number
Specialists Name: Office Location: Locations
Phone Number: .
Health Insurance
Had/Has an Ongoing Medical Condition?

No Yes (Please Describe/State)
Does Your Child Have Any Allergies?

No Yes (Please List All Below, and State If An EpiPen Is Needed)
Had/Has Reactions to Any Medication?

No Yes (Please List All Medications and Reactions Below)
Had An Operation or Hospitalization?

No Yes (Please List All Medications and Reactions Below)
Has your Child Missed 5 Consecutive Days of School Due To Illness or Injury?

No Yes (Please Describe Below)
Had/Has a Bone or Muscle Injury?

No Yes (Please Describe Below)
Has Your Child Ever Passed Out, Had/Has A Concussion or A Serious Head Injury?

No Yes (Please Describe Below)
Had/Has Epilepsy, Seizures, or Convulsions?

No Yes (Please State Which, and Describe)
Had/Has A Vision Problem or Condition?

No Yes (Please Describe In The Box Below.)
Had/Has A Hearing Problem or Condition?

No Yes (Please Describe In The Box Below)
Please CHECK All That Your Child Wears/Has

Glasses Contacts Hearing Aid(s) Cochlear Implant Dental Bridge Braces Mouth Piece
Had Any Immunizations This Past Year?

No Yes (Please Describe In The Box Below)
Had/Has A Hearing Problem or Condition?

No Yes (Please Describe In The Box Below)
Please CHECK Any of The Following That Your Child Currently Has or Has Had In The Past:

ADHD Diabetes Scoliosis Heart Condition(s) Ear Infection Depression Speech Condition(s) Asthma/Trouble Breathing GI Conditions (Ulcer, Reflux, IBS) Urinary Condition Single Organ (Kidney, Testicle) Obsessive Compulsive Disorder (OCD) Oppositional Defiant Disorder (ODD) Headache/Migraines Autism/ Asperger's Nose Bleeds Dental Injurie(s) High Blood Pressure Skin Condition Eating Disorder Anxiety
CURRENT MEDICATIONS

*PLEASE UPDATE SCHOOL NURSE WITH CHANGES THROUGHOUT SCHOOL YEAR*
Please List Name, Dose, and Time(s) Taken
*PLEASE UPDATE SCHOOL NURSE WITH CHANGES THROUGHOUT SCHOOL YEAR*
ASSISTIVE EQUIPMENT
Please CHECK Any of The Following Equipment That Your Child May Use At Home And/Or At School.

Crutches Walker Wheelchair Other
TREATMENTS
Please CHECK Any Of The Following That Your Child May Use At Home And/Or At School.

Insulin/Blood Glucose Monitor Inhaler/ Nebulizer Peak Flow Monitoring Special Diet Other
Please Describe The Special Diet In Which Your Child Is On.
PERMISSIONS:
My child has my permission to receive health/wellness services. I understand the information on this form may be shared with appropriate school personnel in order to meet my child’s safety and healthcare needs. I give permission to exchange information with my child’s primary care physician for the purpose of referrals, diagnosis, and treatments.

Yes No
I give permission to the school nurse to administer over the counter medications to my child per the TRURO CENTRAL SCHOOL MEDICATION PROTOCOLS. To REFUSE one of more of the medications in this protocol CHECK No and list the medications in which you would like to refuse.

Yes No
In the even of a public health emergency, I give permission to the school nurse to administer POTASSIUM IODINE (KI).

Yes No
In the event of a emergency, I give permission to the school nurse to call emergency personnel to have my child transported to the hospital.

Yes No
Parent/Guardian Signature

Clear
Date

Month Day Year
Date
HAND SANITIZER
If you would like your child to OPT OUT of the use of hanitizer at school please sign below. Please know that by leaving the line below blank means your child has permission to use hand sanitizer in school with supervision.

Clear
Should be Empty:

CURRENT MEDICATIONS

ASSISTIVE EQUIPMENT

TREATMENTS

PERMISSIONS:

HAND SANITIZER