Health Information Sheet-Ear Health Formhistory
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1
2HEALTH INFORMATION SHEET Grade_____
Childs name___________________________________Sex_______Birthdate______________________
Home Address_________________________________________Phone___________________________
Step/Mother/Guardian_______________________Occupation________________Work Phone_________
Step/Father/Guardian________________________Occupation________________Work Phone_________
Mother’s Cell Phone__________________________Father’s Cell Phone___________________________
Local Persons to Notify in an Emergency:
Name____________________________Home Phone___________________Work Phone______________
Name____________________________Home Phone___________________Work Phone______________
Name____________________________Home Phone___________________Work Phone______________
Name of local doctor________________________________Phone Number________________________
Has your child had any of the following? When (date or child’s age at onset)?
Anemia
Encephalitis
Meningitis
Scarlet Fever
Asthma
Growth Problems
Mental Health Concerns
Seizures
Broken Bones
Head Injury
Mononucleosis
Tonsillitis
Chicken Pox
Heart Disease
Operations
Tuberculosis
Diabetes
Hernia
Pneumonia
Valley Fever
Divorce
Hepatitis
Pregnancy
Eczema
Influenza
Rheumatic Fever
Is your child going to a hospital, clinic or doctor now? Yes______No______Where___________________
Reason________________________________________________________________________________
Is your child allergic to anything such as food, plants, insects or medication? Yes_______No________
What_______________________________________________________________________________
Is reaction severe enough to require immediate medical attention or medication? Yes________No_______
Is your child able to participate in Physical Education? Yes______No______
Does your child have the following?
Frequent colds
Unusual mood fluctuations
Frequent sore throats
Overweight/Underweight (circle one)
Ear infections
Speech problems
Frequent headaches
Hearing problems
Frequent toothaches
Vision problems
Frequent pain in the legs
Wears glasses/contacts
Frequent stomach aches
Attention Deficit
Please list any additional information that would help the nurse in providing good health care to your
child.____________________________________________________________________________
List any prescriptions or over the counter medication your child is currently taking and
why._____________________________________________________________________________
I give the school permission to discuss this information with staff members who may need to know the
health and well being of my child. Yes_________No_________
I give permission for my child to be treated according to health office guidelines and standing orders.
Yes________No________
______________________________________________
_________________
Parent’s Signature
Date
May 2010
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