## New and Transfer Student Health History Form

Child’s Full Name \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Last First Middle

Male

Female

Birth Date

## Health

check any of the following that your child currently has or has had in the past.

\_\_\_\_Abnormal Spine Curvature (Scoliosis, etc) \_\_\_\_Heart Disease, type\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_ADD/ADHD \_\_\_\_Kidney Disease, type \_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_Allergies or Hay fever \_\_\_\_Measles \_\_\_\_Anemia \_\_\_\_Migraine Headaches \_\_\_\_Arthritis \_\_\_\_Mumps \_\_\_\_Asthma/Wheezing \_\_\_\_Meningitis or Encephalitis \_\_\_\_Behavior Problems \_\_\_\_Nervous twitches/tics \_\_\_\_Birth/Congenital Malformation \_\_\_\_Rheumatic Fever \_\_\_\_Cancer, Type \_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_Seizers of Epilepsy \_\_\_\_Chickenpox, Date \_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_Sickle Cell Disease \_\_\_\_Hepatitis \_\_\_\_Stool Soiling \_\_\_\_Chronic Diarrhea or Constipation \_\_\_\_Substance abuse (alcohol/drugs \_\_\_\_Cystic Fibrosis \_\_\_\_Suicide Attempt \_\_\_\_Depression \_\_\_\_Toothaches/dental problems \_\_\_\_Diabetes \_\_\_\_Tuberculosis (TB) \_\_\_\_Eczema \_\_\_\_Urinary Tract Infections \_\_\_\_Emotional Disorder \_\_\_\_Urinary Accidents (night/day) \_\_\_\_Frequent Headaches \_\_\_\_Other Chronic Health Problems \_\_\_\_Frequent sore throat/infections Explain checked items\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Any condition that would present full participation in educational programs (including physical education) requires physician documentation/orders before modifications can be considered. See your School Nurse for further information.

# Allergies

Allergies -Please list and describe allergies/reactions to: Medication/Drugs\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Treatment\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Foods/Plants/Animals/Other\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Treatment\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Bee Stings/Insect Bites\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Treatment\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

### If your child requires medication for treatment of an allergic reactions during the school day, see your School Nurse for further information.

Injuries and and Illnesses-Please list any severe injuries or illnesses: Illness/Injury Date(s) Hospitalized \_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Yes No\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Yes No\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Yes No\_\_\_\_\_\_\_\_\_\_

- --OVER--