NACP: Permanent Health History Form 2021-22

Permanent Health History Form 2021-22
Student Information
Student 1 Name*

First NameMiddle NameLast Name
Student’s Date of Birth*

MonthDayYear
Date
Gender*

MaleFemale
Last school or children’s center attended
Location
Present Grade
Special Class or School
Health care provider/Physician
Date of last physical exam

MonthDayYear
Date
Family dentist
Date of last dental examination

MonthDayYear
Date
Family Information
Living with child (Names)
______________________________________________________________
Father's Name

First NameLast Name
Health
Mother's Name

First NameLast Name
Health
Stepparent Name

First NameLast Name
Health
Other

First NameLast Name
Health
Brothers

First NameLast Name
How Many Older
How Many Yonger
Health
Sisters

First NameLast Name
How Many Older
How Many Yonger
Health
Has child ever been hospitalized overnight?

YesNo
Name of Hospital
Date of Hospitalization

MonthDayYear
Date
Reason for hospitalization
Is child on medication?

YesNo
Name of medication
Amount
Frequency
Are physical activities limited?

YesNo
If yes, reason for limitation:
Birth History
______________________________________________________________
Mother's Pregnancy
Infections*

YesNo
Bleeding*

YesNo
Toxemia*

YesNo
Sugar Diabetes*

YesNo
Other complications of pregnancy*

YesNo
9-month pregnancy*

YesNo
Type of Delivery
Child's Birth Weight
Child’s birth condition:

GoodPoor
If poor, describe:
Illness During First 2 weeks of life
______________________________________________________________
Trouble Breathing*

YesNo
Seizures*

YesNo
Cyanosis (Blue Color)*

YesNo
Jaundice (Yellow Color)*

YesNo
Feeding problem*

YesNo
Anemia*

YesNo
Birth Defect*

YesNo
Required Incubator*

YesNo
Went home with mother*

YesNo
Child's Illness (past or present)
______________________________________________________________
Chickenpox*

YesNo
Meningitis*

YesNo
Mumps*

YesNo
Rubella (3-day measles)*

YesNo
Rubeola (10-day measles)*

YesNo
Whooping cough*

YesNo
Positive TB skin test*

YesNo
Bronchitis*

YesNo
Pneumonia*

YesNo
Asthma*

YesNo
Hives or Eczema*

YesNo
Drug or other allergy*

YesNo
Head injury*

YesNo
Seizures/Unconscious*

YesNo
Frequent sore throat*

YesNo
Ear aches/infections*

YesNo
Hearing loss*

YesNo
Speech problem*

YesNo
Eye problem*

YesNo
Wears glasses/contacts*

YesNo
Heart condition/Murmur*

YesNo
High blood pressure*

YesNo
Kidney problem*

YesNo
Sugar Diabetes*

YesNo
Blood Disease*

YesNo
Menstrual problem*

YesNo
Hernia*

YesNo
Parasites (worms)*

YesNo
Other serious accidents or illness (describe):
Developmental History
______________________________________________________________
At what age did your child sit alone?
At what age did your child stand alone?
At what age did your child say words?
At what age did your child toilet train?
At what age did your child crawl ?
At what age did your child Walk ?
At what age did your child use sentences ?
At what age did your child use Feed self ?
Check the correct answers
______________________________________________________________
Does your child enjoy Learning?*

YesNo
Does your child like school?*

YesNo
Does your child like other children?*

YesNo
Does your child eat well?*

YesNo
Does your child drink milk?*

YesNo
Does your child eat breakfast?*

YesNo
Does your child sleep well?*

YesNo
Does your child follow directions?*

YesNo
Does your child bite nails?*

YesNo
Does your child suck thumb?*

YesNo
Does your child wet bed?*

YesNo
Does your child seem shy?*

YesNo
Does your child have temper tantrums?*

YesNo
Does your child seem overactive?*

YesNo
What time does your child go to bed?
Do you have any questions or concerns about your child’s health?
Please list your concerns
Parent/Legal Guardian's Signature*

Clear
History taken by (Name)
Title
Submitter's E-mail*
example@example.com
Date
Should be Empty:

Permanent Health History Form 2021-22

Student Information