• Permanent Health History Form 2021-22

  • Student Information

  • Student’s Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Gender*
  • Date of last physical exam
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of last dental examination
     - -
    2 digit month, 2 digit day, 4 digit year

  • Family Information
    Living with child (Names)
    ______________________________________________________________

  • Has child ever been hospitalized overnight?
  • Date of Hospitalization
     - -
    2 digit month, 2 digit day, 4 digit year
  • Is child on medication?
  • Are physical activities limited?

  • Birth History
    ______________________________________________________________

  • Mother's Pregnancy

  • Infections*
  • Bleeding*
  • Toxemia*
  • Sugar Diabetes*
  • Other complications of pregnancy*
  • 9-month pregnancy*
  • Child’s birth condition:

  • Illness During First 2 weeks of life
    ______________________________________________________________

  • Trouble Breathing*
  • Seizures*
  • Cyanosis (Blue Color)*
  • Jaundice (Yellow Color)*
  • Feeding problem*
  • Anemia*
  • Birth Defect*
  • Required Incubator*
  • Went home with mother*

  • Child's Illness (past or present)
    ______________________________________________________________

  • Chickenpox*
  • Meningitis*
  • Mumps*
  • Rubella (3-day measles)*
  • Rubeola (10-day measles)*
  • Whooping cough*
  • Positive TB skin test*
  • Bronchitis*
  • Pneumonia*
  • Asthma*
  • Hives or Eczema*
  • Drug or other allergy*
  • Head injury*
  • Seizures/Unconscious*
  • Frequent sore throat*
  • Ear aches/infections*
  • Hearing loss*
  • Speech problem*
  • Eye problem*
  • Wears glasses/contacts*
  • Heart condition/Murmur*
  • High blood pressure*
  • Kidney problem*
  • Sugar Diabetes*
  • Blood Disease*
  • Menstrual problem*
  • Hernia*
  • Parasites (worms)*

  • Developmental History
    ______________________________________________________________

  • Check the correct answers
    ______________________________________________________________

  • Does your child enjoy Learning?*
  • Does your child like school?*
  • Does your child like other children?*
  • Does your child eat well?*
  • Does your child drink milk?*
  • Does your child eat breakfast?*
  • Does your child sleep well?*
  • Does your child follow directions?*
  • Does your child bite nails?*
  • Does your child suck thumb?*
  • Does your child wet bed?*
  • Does your child seem shy?*
  • Does your child have temper tantrums?*
  • Does your child seem overactive?*
  • Date
  • Should be Empty: