Health Inventory Form Page 2
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4PART I - HEALTH ASSESSMENT
To be completed by parent or guardian
Student’s Name (Last, First, Middle)
Birthdate
Sex
Name of School
Grade
(Mo. Day Yr.)
(M/F)
Address (Number, Street, City, State, Zip)
Phone No.
Parent/Guardian Names
Where do you usually take your child for routine medical care?
Phone No.
Name:
Address:
When was the last time your child had a physical exam? Month
Year
Where do you usually take your child for dental care?
Phone No.
Name:
Address:
ASSESSMENT OF STUDENT HEALTH
To the best of your knowledge has your child any problem with the following? Please check
Yes
No
Comments
Allergies (Food, Insects, Drugs, Latex)
Allergies (Seasonal)
Asthma or Breathing Problems
Behavior or Emotional Problems
Birth Defects
Bleeding Problems
Cerebral Palsy
Dental
Diabetes
Ear Problems or Deafness
Eye or Vision Problems
Head Injury
Heart Problems
Hospitalization (When, Where)
Lead Poisoning/Exposure
Learning problems/disabilities
Limits on Physical Activity
Meningitis
Prematurity
Problem with Bladder
Problem with Bowels
Problem with Coughing
Seizures
Serious Allergic Reactions
Sickle Cell Disease
Speech Problems
Surgery
Other
Does your child take any medication?
No
Yes
Name(s) of Medications: ___________________________________________________
Is your child on any special treatments? (nebulizer, epi-pen, etc.)
No
Yes
Treatment ______________________________________________________________
Does your child require any special procedures? (catheterization, etc.)
No
Yes
Parent/Guardian Signature ___________________________________________ Date:_____________________
Maryland Schools -Record of Physical Examination Revised 12/04
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