School Based Health Center –Family Health History
Student Name:___________________________ Date of Birth: _____/_____/_____Today’s Date: _________________________
Student address: _________________________________________________________________________________________
Parent Name:____________________________ Where does your child usually go for health care?________________________
Name of Primary Care Provider: ___________________________________ Phone #: __________________________________
Name of preferred pharmacy: _____________________________________ Phone #: __________________________________
My child does not have a Primary Care Provider
My child has had a Well Child Check (physical) in the past year. Clinic:_____________________ Phone #:_________________
General Information:
Do you have any current health and/or dental concerns for your child?_______________________________________________
Does your child
Yes
____________________________
What type of reaction did s/he have? _________________________________________________________________________
Does your child have any other allergies (food, cat, mold, dust, pollen)? Yes
No If yes, list allergies:
______________________________________________________________________________________________________
Is your child is currently taking any prescription, non-prescription or herbal medications including any vitamins or supplements?
Yes
No; If yes, please list:
______________________________________________________________________________________________________
Immunization: Check if your child has been immunized for any of the following
Tetanus (in the last ten years)
MMR (measles/mumps/rubella)
Hepatitis A
Flu shot (in the last year)
Other: ______________________________
Hepatitis B
Your Child’s Medical History:
Yes No
Yes No
Serious or chronic illness such as tuberculosis, diabetes,
Blood clot problems?
cancer, hepatitis, mono, ?
Anemia?
Epilepsy/seizures?
Sickle Cell Disease?
Urinary, kidney problems, undescended testicle?
Learning, slowed development or
Missing or damaged organs (eye, kidney, testicle)?
special education needs?
Organ transplant?
Arthritis?
Problems with heart (including murmur), blood
Vision, hearing, or speech
Pressure, or stroke? (circle all that apply)
problems?
Chest pain, shortness of breath, wheezing, or coughing
Mental illness/Depression?
with exercise? (circle all that apply)
Drug or alcohol use or treatment?
Dizziness, fainting, or heat-related illness?
Has it been more than 1 year since
Frequent headaches?
a dental visit?
Head injury, loss of consciousness, seizures?
Injuries or disease to neck, back
Is there a reason why this student should not participate
or other bones or joints
in sports or was ever refused participation for medical
(including fractures)?
reasons?
Please list any major hospitalizations or surgeries, their reason and date:________________________________________
Are you concerned about your child’s drug/alcohol use, sexual activity, or mental health? Explain ___________________
__________________________________________________________________________________________________
Family history: Have any blood relatives ever had any of the following medical conditions/diagnosis?
_____
___
Thyroid disease
Cancer [type] __________
Depression __
Other________________
Please list any additional information about medical history or concerns you have about your child’s health:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Rev 11/19/14
Reviewer: __________ Date:_______