Health History Page 2
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Has your child had trouble with any of the following?
10.
(see question #12 for additional space to write information)
Ears or Hearing:
NO
YES:
If yes, explain: _________________________________
Eyes or Vision:
NO
YES:
If yes, explain: _________________________________
Convulsions or Seizures:
NO
YES:
If yes, explain: _________________________________
Food Intolerance
NO
YES:
If yes, explain: _________________________________
Diabetes
NO
YES:
If yes, provide information on lines #12 and #13 below.
Stomachaches (more than usual) NO
YES:
If yes, explain: _________________________________
Asthma
NO
YES:
If yes, provide information on lines #12 and #13 below.
Bee Sting Sensitivity
NO
YES:
If yes, describe reaction: _________________________
Allergies
NO
YES:
If yes, describe: ________________________________
Colds
NO
YES:
If yes, explain: ________________________________
Fevers
NO
YES:
If yes, explain: _________________________________
11. Does your child have any other special health needs or problems not listed above that the school should
know about?
NO
YES: If yes, explain: _________________________________
__________________________________________________________________________________________
12. Please use this space to further explain any of the items mentioned in #10 and #11 as necessary. ___________
__________________________________________________________________________________________
__________________________________________________________________________________________
13. What do you want the school nurse to do about any of the above discussed problems if anything should
occur in school?
__________________________________________________________________________________________
__________________________________________________________________________________________
14. Tuberculosis (TB) Risk Assessment: Routine skin testing for tuberculosis in children with no risk factors is
not recommended; therefore, the following questions will help to determine whether your child is considered to
be at increased risk for acquiring tuberculosis.
1.) Has your child had any contact with an adult with infectious tuberculosis?
NO
YES
2.) Were you or your child born, or did you live in a country where TB is common (
e.g., Asia, Africa, Caribbean
NO
YES
Islands, Latin America, Mexico, Middle East, Philippines, Russian Fed., or South America)?
3.) Does your child have any of the following medical risk factors: Diabetes, chronic kidney failure, chronic
respiratory disease, or chronic illness associated with malnutrition?
NO
YES
4.) Does your child have a disease or receive treatment that affects his or her immune system, such as cancer,
leukemia, lymphoma, Hodgkin’s disease, or HIV infection?
NO
YES
5.) Does your child have frequent contact with persons in any of the following groups: Residents of nursing
homes, migrant farm workers, IV drug abusers, HIV positive persons, homeless individuals, or
incarcerated persons?
NO
YES
Person completing health history ___________________________________ Date_____________________
(Signature)
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