School Physical Health History Form- to be completed for all School Physicals
Student's Name
*
First Name
Last Name
Student's Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Sex assigned at birth (M, F)
*
Preferred Prounouns (he, she, they, etc)
School Attending in Fall (East, West, South, Frost)
*
Grade or Student ID Number
HEALTH HISTORY
TO BE COMPLETED AND SIGNED BY PARENT/GUARDIAN AND VERIFIED BY HEALTH CARE PROVIDER
ALLERGIES
Allergies (medication, food, insects, etc)
*
Yes
No
List any allergies you have:
Do you take any daily medications?
*
yes
no
List the medications
Please answer the following health history questions about your child:
*
Rows
YES
NO
Diagnosis of Asthma?
Child wakes during the night coughing?
Birth Defects?
Developmental Delays?
Blood Disorders (Hemophilia, Sick Cell Disease, other)
Diabetes?
Head Injury/Concussion/Passed out?
Seizures?
Heart Problem/Shortness of Breath?
Heart Murmur/High Blood Pressure?
Dizziness or chest pain with exercise?
Wears Glasses?
Ear/Hearing problems?
Bone/Joint problem/injury/scoliosis?
Loss of function of paired organs? (eye, ear, kidney, testicle)
Past Hospitalizations?
Past Surgeries?
Serious injury or illness?
Past or present TB skin test that came back positive?
Tuberculosis disease (past or present)
Tobacco use?
Alcohol/Drug use?
Family History of sudden dealth before age 50?
Dental: do you have braces?
Any questions you'd like to explain? (type of surgery, date of concussion, etc)
Parent/Guardian Signature:
*
Today's Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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