FORM 13 Page 1
HEALTH HISTORY
Youth Last Name
Youth First Name
/
/
Date of Birth
County / Placing Agency
Having accurate medical background information at the time of admission assists our medical staff in planning and
providing the best possible care for each youth. Please complete this form. Include the names and telephone numbers
for all medical/dental providers who continue to provide specialized care for the above-referenced youth.
Family Health History: Please check below if the grandparents, aunts/uncles, parents, or siblings have the following
health conditions:
diabetes
heart disease
stroke
asthma
hepatitis
sickle cell disease / trait
HIV infection
cancer
heart attack
blood clots
seizures / epilepsy
high blood pressure
depression
death by suicide
tuberculosis
thyroid disease
alcohol / drug addiction
 Other:
Youth Health History: Please check all that apply.
asthma
seizures / epilepsy
chicken pox
hearing problems
suicide attempt(s)
diabetes
heart condition
vision problems
speech problems
injuries (explain below)
enuresis (bed wetting)
loss of bowel or bladder control
headaches, migraines
depression
surgery (explain below)
No known allergies
Allergies to the following medications:
Allergies to the following foods:
Other allergies:
CURRENT MEDICATIONS
Name of medication
Daily dosage/times given
Reason for taking
FORM 13 Page 2
YOUTH LAST NAME, FIRST NAME
INSURANCE INFORMATION
Primary Insurance Name
Policy / Agreement #
Group #
Name of Policy Holder:
Secondary Insurance Name:
Policy / Agreement #
Group #
Name of Policy Holder
Coverage
Employer:
Coverage
Employer:
Is youth currently receiving state medical assistance?
Yes
No
Under the Pennsylvania Department of Human Services Guidelines, the following immunizations are required by
all children, grades K-12:
4 doses of diphtheria (1 dose on or after the 4th
birthday)
2 doses of varicella (chickenpox) or evidence of
immunity
3 doses of polio
3 doses of hepatitis B
2 doses of measles
1 dose of rubella (german measles)
7th Grade ADDITIONAL requirements for every child include:
1 dose of meningococcal conjugate vaccine (MCV)
1 dose of tetanus, diphtheria, acellular pertussis (Tdap) IF five (5) years have passed since the last tetanus
immunization was given.
Please attach a copy of the youth’s immunizations with this Health History form. If you do not have this information,
list the name, city, and state of the public school the youth most recently attended.
Name of School
City State Zip
Please note below the names, phone numbers, and treatment provided for any medical, dental, psychiatric, or other
health provider who recently cared for this youth.
Name
Phone Number
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/
/
/
/
Treatment Provided
/
/
/
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233 George Junior Road  P.O. Box 1058  Grove City, Pennsylvania 16127  724-458-9330 Ext. 2100  Fax: 724-458-8401