Health History Form
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1GREAT NECK PUBLIC SCHOOLS
Health Services
Health History
To be completed by PARENTS/GUARDIANS of entering students
Student’s Name: ____________________________________________________________________________
Last
First
Middle
Student’s Date of Birth: ____/____/____ Sex_____ Number of Children in Family_____State or Country of Birth________________
Student’s Address_________________________________________ City__________________ State_________
Zip_________
Name of School_________________________________________________________________Grade ________________________
Name of Mother or Legal Guardian_______________________________________________________________________________
Home Phone_________________________ Work Phone_________________________ Cell Phone___________________________
Name of Father or Legal Guardian________________________________________________________________________________
Home Phone_________________________ Work Phone_________________________ Cell Phone___________________________
Medication Allergies: _______________________________________________________________________
Food Allergies: ____________________________________________________________________________
Other Allergies (i.e., insect bites, etc.):__________________________________________________________
Chronic, Recurring and/or Special Health Conditions
Check any that apply and explain below
Arthritis
Heart Disease
Asthma
Kidney Disease/UTI
Attention Deficit – Hyperactivity Disorder
Inflammatory Bowel Disease
Behavior or Developmental Problems
Mononucleosis
Cerebral Palsy
Multiple Ear Infections
Chicken Pox
Neurological Disorders
Cystic Fibrosis
Pervasive Developmental Disorder/Autism
Dental Problems
Seizures
Diabetes
Sickle Cell Disease (not trait)
Encopresis (involuntary discharge of stool)
Visual Impairment
Daytime Enuresis (involuntary discharge of urine)
TB/Positive PPD
Head or spinal injury
Scoliosis
Hearing Impairment
Illness/Injury
Describe any family history of chronic illnesses or genetic concerns. Please list family member in relation to
child (i.e. mother) and name of condition (i.e. anemia, arthritis, cancer, diabetes, heart disease, high blood
pressure, kidney disease, mental illness, stroke, tuberculosis) ________________________________________
__________________________________________________________________________________________
List names of medical specialists or special clinics caring for your child: _______________________________
__________________________________________________________________________________________
Describe your child’s operations and hospitalizations, if any (reason and date): __________________________
__________________________________________________________________________________________
Describe any other important health-related information about your child: ______________________________
__________________________________________________________________________________________
For the safety of my child, I give permission to discuss confidential information with appropriate school
personnel.
Signature of Parent or Legal Guardian______________________________________Date_________________
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