Au Sable Valley Central School Health Certificate / Appraisal Form (Page 2 of 2) in pdf

HEALTH HISTORY

Child’s Name:

Age:

Birth date:

___ __

Address:

___ __

Phone Number:

Name of Family Physician or Provider:_________________________________________

________________________________________________________________________

To be completed by parent/guardian:

Health History during last 12 months:

 Yes  No

Does this child have an ongoing health concern? (asthma, diabetes, etc.)

 Yes  No

Does this child have any chronic illnesses or conditions?

 Yes  No

Does this child have any allergies to medication, food or environmental?

 Yes  No

Does the allergy require emergency treatment, such as EPI-PEN?

 Yes  No

Does this child have problems with blood pressure, heart, or heart murmur?

 Yes  No

Is there a history of any hospitalizations, significant injuries, or surgery?

 Yes

 No

Any dizziness, fainting, convulsions, seizures, or headaches?

 Yes  No

Does this child have any problems with liver, spleen, kidneys, etc.?

 Yes

 No

Are there any CURRENT medical concerns/injuries? See below

 Head/concussion

 Glasses/contacts__________

 Eyes

 Ears____________

 Hearing_________________________

 Throat _

 Nose /Nose bleeds

__________

 Chest

 Respiratory

 Cough

 Neck_________

 Cardiovascular

 Gastrointestinal

 Heat exhaustion/stroke______________

 Genitourinary

 Neurological

 Skin disease __

__ _________

 Musculoskeletal (include any fractures, etc.)

___ ____

_________

 Hernia

 Teeth

 Dental appliances

____

_________

 Yes

 No

Does this child take any medication regularly at home?

 Yes

 No

Require medication at school?

 Yes

 No

Is this child on any special diet or food restrictions?

Describe child’s nutritional pattern and dietary intake:

List any significant medical concerns or sudden death of family members:

 Mother__________________ Father

 Grandparents

 Siblings

 Other

Please describe any YES responses:

____________________________________________________________________________

________________________________________________________________________________

The above information is current and correct to the best of my knowledge.

By signing this form, I consent to my child’s physical exam and for the release of medical

information to the school and/or the health care provider.

Parent/Guardian Signature:

Date:

Please be sure to COMPLETE the HEALTH HISTORY and SIGN BOTH SIDES of this form.

Au Sable Valley Central School Health Certificate / Appraisal Form Page 2

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