School Health History Form Page 2
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1
24.
Has your child had a serious illness or injury since birth?
Yes
No
5.
Were there any problems with the pregnancy, labor, delivery or soon after birth for this child?
Yes
No
If yes, please describe what type and when:
6.
Has this child ever needed to stay in the hospital or had any operations?
Yes
No
If yes, please describe why and when:
7.
DEVELOPMENTAL HISTORY:
Child sat without support:
5-7 months
8 months or later
Child walked alone:
Before 14 months
After 14 months
Child spoke single words:
11-20 months
After 21 months
Child began combining words into sentences:
14-24 months
After 24 months
8.
VISION HISTORY:
Yes No
I have concerns about my child's vision
Family members have vision problems
Child wears glasses
Child is blind or visually impaired
Eyes appear to cross
Has had eye exam
9.
HEARING HISTORY:
Yes No
Frequently does not hear directions
This child has a hearing problem/impairment
Family members have hearing problems
Has had tubes in ears
Frequent ear infections/earaches
10.
LANGUAGE HISTORY:
Yes No
Child has noticeable speech problem. Please Explain:____________________________________________________________
Trouble understanding directions or questions.
Unable to follow 2 directions given at the same time.
Friends/relatives do not seem to understand most of what child says.
There is a second language spoken at home. Other Lanuage:______________________________________________________
Child is:
talkative
average
silent and quiet
11.
GENERAL HISTORY:
Yes No
There has been a frequent move, death, divorce, separation
Has difficulty talking and playing with other children
Frequently stumbles or falls when running or walking
Has behavior habits that concern me
Overly active compared to other children
Other: Please Explain:______________________________________________________________________________________
Is there anything more about your child that you think is important for us to know?
Yes
No If yes, please comment:
Parent Signature
Date
District Nurse Signature
Date
Updated 12/8/2011
Page 2
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