Health History
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1
2WARWICK SCHOOL DISTRICT
HEALTH HISTORY
_______________________
Date
Name: _______________________________________________________________________________________
Last
First
Middle
Address: _____________________________________________________________________________________
Phone: ____________________________________
Birthdate: ________________________________________
Father’s Name: _____________________________ Mother’s Name: ___________________________________
Name of School: ____________________________________ Grade: ______________ Age: _______________
HEALTH BACKGROUND
Information relative to your child’s health may be shared with appropriate school personnel when necessary to meet your
child’s educational, health, and safety needs.
1.
Please give the dates or approximate age that your child had the following diseases:
Chicken Pox __________
Pneumonia ___________
Rheumatic Fever __________
Infectious Mononucleosis __________
Other ____________________________________________________________________________________
2.
Has your child ever been in the hospital or had an operation?
NO
YES
If yes, when? _______________________ Reason: ______________________________________________
__________________________________________________________________________________________
3.
Has your child had any other illnesses, accidents, or broken bones?
NO
YES
If yes, when? _______________________ What problem? ________________________________________
_________________________________________________________________________________________
Name of child’s doctor or clinic: ______________________________________________________________
4.
5.
Is your child receiving treatment from a doctor or clinic at present?
NO
YES
If yes, explain: _____________________________________________________________________________
6. Is your child taking medicines?
NO
YES
If yes, what? ______________________________
Why? ________________________________________
7. Has your child ever been seen by a dentist?
NO
YES
Name of dentist ________________________________________ Date of last visit: ____________________
8. Is your child restricted from physical activity?
NO
YES
If yes, explain: _____________________________________________________________________________
9. Does your child need special seating in the classroom?
NO
YES
If yes, explain: _____________________________________________________________________________
OVER
Revised 2/04
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