HEALTH HISTORY FORM

2006 – 2007 SCHOOL YEAR

Child’s Name _______________________________Today’s Date ____________

Grade__________________ Date of Birth ______________________

Address __________________________________________Phone ____________

Parent’s Name________________________________ Work # ______________

Emergency Contact_____________________________ Phone________________

Physician’s Name_______________________________ Phone _______________

Medical Insurance Co.__________________________ Policy #______________

A. Illnesses and Injuries: (Check those that apply)

____Asthma ____Diabetes ____Epilepsy ____Kidney ____Disease

____Convulsions/Seizures ____Ear Infection ____Heart Disease

Date of last health exam______________ Medical problems noted ______Yes ____No

If yes, please explain _____________________________________________________
_______________________________________________________________________
_______________________________________________________________________

If the child has had any of the following since his/her last exam, please explain:

A serious illness ____________________________________________________

An illness longer than a week _________________________________________

An operation or fracture _____________________________________________

Treatment in a hospital or emergency room ______________________________

Restrictions from physical activity _____________________________________

Medication to be taken on a regular basis ________________________________

B. Allergies: (Check those that apply):

_____Animals Medicines _______Plants Hay Fever ______Insect Stings ______Pollen

_____Food ______Other Please specify if any are checked

C. Immunizations:

Immunization Year Primary Series Completed Year of Last Booster

DPT _______________________ ________________

Measles _______________________ ________________

Mumps _______________________ ________________

Oral Polio _______________________ ________________

Rubella _______________________ ________________

TB Tine _______________________ ________________

Chicken Pox _______________________ ________________

HIB Hepatitis _______________________ ________________

D. Other Health Conditions: __________________________________________

E. Permission to seek medical help:

IF I CANNOT BE REACHED IN CASE OF AN EMERGENCY, THE BEARER OF THIS FORM IS AUTHORIZED TO ACT ON MY BEHALF TO SEEK MEDICAL TREATMENT, AS THEY DEEM NECESSARY FOR MY CHILD.

F. Individuals permitted to pick up child/ren: ___________________________________

Signature of Parent/Guardian Date ___________________________________________