School Health History Form

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School Health History Form
District Nurse Phone: 262-560-2104
District Nurse Fax: 262-560-2106
Dear Parent:
We would like your child to gain the most from his/her school experience. In order for us to assist in accomplishing this, it is
necessary to have a current health history. Please complete this form and return it to your child’s school when you register.
Child's Name
Sex
Birthdate
Address
School Attending
Telephone
Father's Name
Mother's Name
1.
FAMILY HISTORY:
Number of children in the family
. This child's rank in family
.
Please check (√) the following if applicable to this child or his/her immediate family:
Family
Family
This Child
Member
This Child
Member
ADHD/ADD
Heart disorder
Anemia
Kidney problems
Asthma
Learning disability/problem
Autism
Mental retardation
Bleeding disorders
Muscle disorders
Bone disorders
Neurologic disorders
Cancer, tumors
Obesity/Weight Problems
Convulsive disorder/seizures
Sickle cell
Cystic fibrosis
Speech/Language Problems
Diabetes
Other (Fill in)
Emotional problems
Food Allergies
If you checked that your child has a health problem, please explain:
Does your child have allergies?
Yes
No If yes, to what?
Date of last reaction
What happened?
Is an Epi-Pen prescribed for allergy?
Yes
No
2.
MEDICATIONS
Is your child currently taking medication(s) at home?
Yes
No
Name of medication(s)
Do you anticipate your child will need to take medications (including as needed meds – Tylenol, Bendadryl, etc) at school?
Yes
No
Name of medication(s)
3.
HEALTH HISTORY
How is health care provided for this student?
Employment Insurance
Private Insurance
Social Security Insurance
Medicaid
Other
When did your child have a physical examination?
Date
Physician/Clinic
When did your child have a dental check-up?
Date
Dentist
***more on reverse***
Updated 12/8/2011
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