Form Language
STUDENT HEALTH FORM
PLEASE TYPE OR PRINT YOUR ANSWERS IN THE SPACE PROVIDED FOR EACH ITEM
1. NAME OF STUDENT:
2. HEALTH HISTORY
2.1 Does your child take any medication?
Yes
No
If Yes, explain
2.2 Does your child have a health condition that school personnel should know about?
Yes
No
If Yes, explain
3. Immunization Information Record dates of initial childhood and last immunization:
Polio
Hepatitis A
TB Skin Tests
Meningitis
Hemophilia Influenza
Other
DTP-DT (Diphtheria/Tetanus/ Pertussis )
MMR (Measles /Mumps/ Rubella)
Chicken Pox
Hepatitis B
BCG
4. Developmental Information:
4.1 Were there any complications in the pre-natal, delivery, or post-natal periods?
Yes
No
If Yes, explain
4.2 Any present or past sleeping or eating problems?
Yes
No
If Yes, explain
4.3. Please, check the following items where appropriate and give date of occurrence:
Broken Bones
Intestinal Problems
Head Injuries
Allergies
Hearing
Hospitalizations/operations
Vision
High Temperatures
Seizure
Other
If any of the above items are checked, please give additional details:
