After School Program Health History Form

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After School Program
HEALTH HISTORY FORM
Name :
M / F
Date of Birth________________
:
Age at Start of School:
State:
Address:
City:
Cell:
Home Phone
Nickname:
Parent / Guardian / Emergency Contact
Name:
:
Zip:
Address:
City:
E-mail:
Home Phone
Cell:
Emergency Contact
Name:
Insurance Information
Medicines that will need to be administered at the After School Program MUST BE in
Medications
original container and include the child’s name, dose and frequency. All
Child is covered by family medical/hospital insurance
Yes
No
medications will be dispensed as directed on bottle. Any Changes need a
doctor’s note.
Insurance Company:
Phone:
Policy Number:
Group/ID Number:
Name of Policy Holder:
Health Care Providers
Primary Doctor:
Phone:
Phone:
Dentist:
Immunization History
Provide the month and year for each immunization (or attach a copy of immunization record)
Dose 1
Dose 2
Dose 3
Dose 4
Dose 5
TB Test
Date:
( Month/Year )
( Month/Year )
( Month/Year )
( Month/Year )
( Month/Year )
Diptheria, Tetanus, Pertussis (DTaP or TdaP)
Positive
Negative
Mumps, Measles, Rubella (MMR)
Polio (IPV)
Tetanus
Haemophilus Influenzae Type B (HIB)
Date:
(dT or TdaP)
Pneumococcal (PCV)
Hepatitis B
Influenza
Hepatitis A
Seasonal
Date:
Date:
Varicella (Chicken Pox)
Had Chicken Pox?
Meningococcal Meningitis (MCV4)
H1N1
Date:
General Health History
Check "Yes" or "No" for each statement.
1. Ever been hospitalized?...................................................
13. Had high blood pressure?..............................................................
No
No
Yes
Yes
2. Ever had surgery?............................................................
14. Have problems with diarrhea / constipation?.................................
No
No
Yes
Yes
3. Have recurrent / chronic illnesses?..................................
15. Had frequent ear infections?..........................................................
No
No
Yes
Yes
4. Had a recent infectious disease?.....................................
16. Have problems with falling asleep/sleepwalking?.........................
Yes
No
No
Yes
5. Had a recent injury?.........................................................
Yes
17. Wear glasses, contacts, or protective eyewear?...........................
No
No
Yes
Yes
6. Had asthma / wheezing / shortness of breath?................
18. Ever had back / joint problems?....................................................
Yes
No
No
Yes
7. Passed out/had chest pain during exercise?...................
19. Have any skin problems?..............................................................
Yes
No
No
Yes
8. Had seizures?..................................................................
20. Have diabetes?..............................................................................
Yes
No
No
Yes
9. Had fainting or dizziness?................................................
21. Had "mono" in the past 12 months?..............................................
Yes
No
No
Yes
Yes
10. Had headaches?............................................................
22. Traveled outside the country in the past 9 months?......................
No
No
Yes
11. Had a head injury?.........................................................
No
Yes
12. Been knocked unconscious?.........................................
No
Yes
Mental, Emotional, and Social Health
Check "Yes" or "No" for each statement.
1. Ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (ADHD)?.............................................................
No
Yes
No
2. Ever been treated for emotional or behavioral difficulties or an eating disorder?....................................................................................................
Yes
3. During the past 12 months, seen a professional to address mental/emotional health concerns?...........................................................................
No
Yes
4. Had a significant life event that continues to affect the student’s life?
....
(abuse, death of a loved one, divorce, adoption, foster care, new sibling, survived a disaster)
No
Yes
Standing Medication Orders
The following non-prescription medications may be stocked in the facility and used on an as needed basis to manage
illness or injury. My child has permission to take or use the following:
___ Tylenol/ Acetaminophen ___ Tums/ Antacid ___ Pepto Bismol/ Imodium
___ Sudafed/ Decongestant
___ Topical creams and ointments
___ Benadryl/ Antihistamine ___ Advil/ Ibuprofen ___ Robitussin/ Expectorant ___ Swimmers’ Ear/ Alcohol Vinegar Solution
*We do not apply sunscreen or insect repellent

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