Student Health History

Student Health History
We would like your child to gain the most from his/her school experience. In order for us to assist in accomplishing this, it is necessary to have a current health history. Please complete this form and return it to the school nurse as soon as possible. All information contained in this questionnaire is strictly confidential and will become part of your child's medical record.
Child's Name (Last, First)*
Gender*
Date*

MonthDayYear
Date
Address
Phone
Father's Name
Father's Email
example@example.com
Mother's Name
Mother's Email
example@example.com
Brothers
Sisters
With whom does the child live?
Date of last physical exam

MonthDayYear
Date
Personal Health History
Childhood illness

MeaslesMumpsRubellaChickenpoxRheumatic FeverPolio
Please attach a copy of child's immunization record

Cancelof
Does your child have a health issue? (Check where appropriate)

AsthmaAnemiaAllergiesADD/ADHDDepressionDiabetesHearingHeartInjurySeizures/ConvulsionsSickle Cell AnemiaVision
Explain
Medications
Does your child take medication?
Name of medication(s)
If your child is on PRESCRIPTION medication: please fill out the release form available at the nurse's office.

If necessary, would you like the school nurse to administer any of the following medications

Is there anything more about this childs health that you think is important for me to know
ParentsGuardians Signature

Clear
Date

MonthDayYear
Date
Should be Empty: