Student Health History Form
Grades K-12-Print-Fill Out-Bring To Enrollment
by Katie Kettler
April 03, 2009
STUDENT HEALTH HISTORY (DATE/YEAR)______________
Student Name _______________________________________ Date of
Birth__________ Grade __________
This questionnaire is designed to provide an overview of your
child’s general health. This information will assist the staff in
providing the best possible care with regards to your child’s
health. This information will be kept in your child’s confidential
school health record. Thank you for help.
Katie L. Kettler, RN, School Nurse Nancy A. Ramer, RN, School
Nurse
Does your child have: (please check all that apply)
Asthma/breathing difficulties ______________
If YES, does your child use an inhaler? Yes / No
Diabetes _______________
Seizures ______________
Attention Deficit/Hyperactivity Disorder _________
If YES, does your child take medication for this? Yes / No
Does your child have any other current health problems not listed
that the school should be aware of? Yes / No.
If YES, please list below:
Does your child take any medications on a regular basis? Yes / No.
(If YES, please list the name of medication, dose, and number of
times taken per day).
Will your child need to take any medication at school? Yes /
No.
Does your child have any FOOD or DRUG allergies? Yes / No. (If YES,
please list: side effects if ingested would also be helpful).
Has your child had any surgeries? Yes / No. (If YES, please list
type of surgery and age or year of occurrence).
Please list previous illnesses (example: Chicken Pox, Chronic Ear
Infections, Hospitalizations for Illnesses. Also if your child has
had CHICKEN POX, please list year and month this occurred):
YES / NO I give permission for this information to be shared with
my child’s teachers, activity sponsors/coaches, and/or
administrative staff on a need-to-know basis.
It is the responsibility of parent or legal guardian to inform the
school health nurse at any time there is a change in medication,
medical status/diagnosis, or if a medical concern arises with your
child.
Parent/Guardian Signature
____________________________________________ Date
________________
