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LEARNING PREP SCHOOL
1507 Washington Street, West Newton, MA 02165
(617) 965-0764
STUDENT HEALTH HISTORY
Name of Student:
Sex:_________
Birth date:_______________________
Place of Birth - Town:____________________________________ State:___________
Primary Doctor:
Date last visit:
Address:
Phone: (
1.
Student SS #_____________________
)
Please indicate if your child has any major medical condition or illness.
Check if applies
Check if under treatment
Explain
[ ] Seizures or convulsions
[]
[ ] Asthma
[]
[ ] Bleeding disorder
[]
[ ] Heart problem
[]
[ ] Lung or breathing problems
[]
[ ] Kidney disease
[]
[ ] Others
[]
[]
[]
[]
2.
Has your child ever been hospitalized or had an operation?
(Continue on reverse side, if necessary)
a.
Date
yes( )
no( )
Hospital
Condition
b.
Date
Hospital
Condition
c.
Date
Hospital
Condition
3.
4.
List all medications your child is taking: (Continue on reverse side, if necessary)
Medication
Dose
Time(s) Taken
Medication
Dose
Time(s) Taken
Medication
Dose
Time(s) Taken
Does your child have any allergies?
yes( )
Foods
Medications
Insects
Other Things
Does your child need treatment for these allergies? yes( ) no( )
Explain
no( )
Student Health History - Page 2
5.
Student Name ______________________________________________
Indicate if your child has any serious problems with any of the following conditions:
Check if Applies
Check if Under treatment Explain
[ ] Eczema or persistent rash
[]
[ ] Frequent headaches
[]
[ ] Dizzy or fainting spells
[]
[ ] Frequent colds (more than 5/year)
[]
[ ] Recurrent ear infections
[]
[ ] Difficulty swallowing solids
[]
[ ] Difficulty swallowing liquids
[]
[ ] Frequent nosebleed
[]
[ ] Persistent cough or wheeze
[]
[ ] Frequent stomach ache, nausea, vomiting
[]
[ ] Trouble with bowel movements
[]
[ ] Frequent urination/burning/pain on urination
[]
[ ] Urine (bladder) or kidney infection
[]
[ ] Trouble with feet or walking
[]
[ ] Clumsiness using hands or feet
[]
[ ] Posture problem
[]
[ ] Curvature of spine
[]
[ ] Painful joints
[]
[ ] Anemia (low blood)
[]
[ ] Exposure to lead
[]
[ ] High blood pressure
[]
[ ] Blueness (cyanosis)
[]
[ ] Tires easily
[]
[ ] Frequent nightmares
[]
[ ] Overweight
[]
[ ] Hearing loss
[]
[ ] Vision problems
[]
[ ] Dental problems
[]
[ ] Hyperactivity
[]
[ ] Attention problems or daydreaming
[]
[ ] Emotional problems
[]
[ ] Poor appetite
[]
[ ] Bedwetting
[]
[ ] Trouble with sleep
[]
Student Health History - Page 3
6.
Student Name ______________________________________________
Check if your child needs any special aids or equipment.
[ ] Glasses
[ ] Hearing Aid
[ ] Prosthesis
[ ] Crutches/Braces/Canes
[ ] Other_____________________________________________________________________
7.
Are there any family problems or health conditions which create a problem for your child? yes ( ) no ( ) Please Explain:
8.
If your child is a female and has begun her menstrual period?
yes ( ) no ( )
Does your daughter require any assistance with personal care during her periods: yes ( ) no ( )
9.
please explain:
List the doctors or clinics who are involved in your child's care:
Address
Neurologist
Orthopedist
Ear-Nose-Throat
Allergist
Ophthalmologist
Gynecologist
Psychologist/Psychiatrist
Audiologist
Dentist
Specialty Therapists
Other
Phone No.
Student Health History - Page 4
Student Name ______________________________________________
10. What was the date of your child’s last DENTAL EXAM date_______________ within the last year:
(THIS IS A REQUIREMENT).
11. Are there any recommendations by physicians or educational specialists that you do not understand or have been unable
to implement?
yes ( ) no ( ) please explain:
12. Are there any problems which should be brought to the attention of the school nurse?
explain:
yes ( ) no ( )
please
13. Do you have any other concerns which should receive individual attention or consideration?
explain:
yes ( ) no ( )
please
Signature
Date:
Relationship to Student: