Pine Richland School District
Health History
Student Name:__________________________________
Mother
Date of Birth:_____________________
Father
Parent’s Name
Address
City, State
Phone
Employer
1. Special Health Needs (Circle Yes or No)
Has your child ever had any serious illness or operations: ……………………………………….
What?______________________________ When?_________________________________
Yes No
Is your child going to a hospital, clinic or doctor now? …………………………………………
What for?___________________________ When?_________________________________
Yes No
Apart from vitamins, is your child taking any medicine, tablets or drugs? ………………………
What?______________________________ What for?______________________________
Yes No
Does your child need to take any medicine, tablets, or drugs at school? …………………………
What?______________________________ What for?______________________________
Yes No
Is your child allergic to anything, such as foods, plants, insects, medicine? ……………………
What?_____________________________________________________________________
Yes No
Has your child had any convulsions (fits, seizures) in the past year? ……………………………
How many?__________ Treatment_____________________________________________
Yes No
Does your child need a special diet or have any food problem? ………………………………….
Give details________________________________________________________________
Yes No
Does your child have any special health needs or problems the school should know? …………..
What?____________________________________________________________________
Yes No
Has your child had any other illnesses, accidents, broken bones? ………………………………..
When?_________________________ What was the problem?_______________________
__________________________________________________________________________
Yes No
2. Health History
(Check any of the following illnesses your child has had):
 Whooping Cough
 Chicken Pox Date ___/____/___
 Rheumatic Fever
 Pneumonia
(Circle Answer):
Has your child had more than six colds or throat infections, with a fever, a year? …………. Yes No
Has your child had any trouble with ears or hearing? ……………………………………….. Yes No
Has your child had any trouble with eyes or seeing? ………………………………………… Yes No
Has your child had any trouble with teeth? …………………………………………………..
Yes No
Has your child ever had a convulsion (fit or seizure)? ………………………………………. Yes No
Has your child ever had a fainting spell? …………………………………………………….. Yes No
Does your child complain of headaches? ……………………………………………………. Yes No
Has a doctor ever said your child had a heart murmur? ………………………………………. Yes No
Do any foods disagree with your child? ………………………………………………………
Yes No
Does your child often have diarrhea? ………………………………………………………… Yes No
Has constipation ever been much of a problem for your child? …………………………….. Yes No
Have you ever seen blood in your child’s stools (bowel movements)? ……………………… Yes No
Has your child ever had yellow jaundice or trouble with the liver? …………………………. Yes No
Does your child complain of bellyaches? ……………………………………………………
Yes No
Student Name:_____________________________Date of Birth: _________________
2. Health History (Continued):
Does the child have any problems with passing water (urination)? ………………………… Yes No
Does the child have any skin problems? …………………………………………………….
Yes No
Has the child ever had eczema or allergy? ………………………………………………….
Yes No
Has the child ever had asthma or wheezing? ……………………………………………….. Yes No
Has the child ever had an allergy or reaction to any medicines or injections? …………….. Yes No
What was the medicine or injection? ________________________________________________
Does the child seem to have trouble breathing through the nose? …………………………. Yes No
Does the child snore at night? ………………………………………………………………
Yes No
Has the child ever complained or pain in the arms or legs? ……………………………….. Yes No
Has the child ever had swelling of any joints or limping? …………………………………Yes No
Has there ever been any trouble with the child’s blood? ………………………………… Yes No
Does the child have any trouble sleeping? ……………………………………………
Yes No
3. Pre-Natal Health History (Circle Answer) :
1. Did the mother have any illness during pregnancy? ………………………………………… Yes No
2. Did the mother take any medicines or drugs (other than iron or vitamins) during
the pregnancy? ……………………………………………………………………………….
Yes No
3. Did the baby come on time? ………………………………………………………………….
Yes No
4. Developmental History
1. What was the baby’s birth weight? ___________
2. Did the baby have any trouble while in the hospital ………………………………………… Yes No
3. Did the baby have any special problems in the first six months? …………………………….Yes No
4. At what age did the child sit alone without support? ___________
5. At what age did the child walk alone without support? ___________
6. At what age did the child begin to say two or three words together? ___________
7. Can the child use the toilet without help? …………………………………………………… Yes No
8. If the child has stopped wetting the bed, at what age did he/she stop? ___________
Any Special Health concerns you would like to share with the school nurse?
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Health History obtained from:
_____________________________________________ Date:_________________________
Parent/Guardian
Revised 02/09