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Oceanside Middle School Student Health History
Note: Information shared with school personnel is at your discretion.
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* Indicates required question
Student's Full Legal Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Street Address
*
Your answer
Telephone Number
*
Your answer
Mailing Address
*
Your answer
People Living in Household
*
Mother
Father
Step Parent
Other:
Required
Other Children Living in Household (Name(s) and Age(s)
Your answer
Physician's Name
*
Your answer
Physician's Address and Office Telephone Number
*
Your answer
Date of Last Physical
*
MM
/
DD
/
YYYY
Dentist's Name
*
Your answer
Dentist's Address and Office Telephone Number
*
Your answer
Date of Last Visit
*
MM
/
DD
/
YYYY
Has your child had:
*
Chickenpox
Pneumonia
Seizures/Convulsions
Scarlet Fever
Polio
Rheumatic Fever
Heart Condition
Tuberculosis
Measles
Pertussis (Whooping Cough)
Meningitis
Encephalitis
Hepatitis
Eye Injury or Disease
Head Injury
Mononucleosis
Speech Therapy
Occupational Therapy
Physical Therapy
None of the above
Other:
Required
Does your child have:
*
Asthma
Diabetes
Seizure Disorder/Epilepsy
Allergies (be specific - food, medication, etc.)
Bee sting/anaphylaxis allergy (medication required?)
Frequent ear infections
Had hearing tested
Hearing problems
Vision problems
Color blind
Had vision tested
Wears glasses
Speech problems
Heart problems
Frequent skin rashes
Frequent colds
Bowel problems
Frequent urination
Bone/joint problems
Poor coordination
Learning disabilities
None of the above
Other:
Required
Handicapping condition?
*
Yes
No
If 'yes', please explain.
Your answer
Has your child received services from any community agency such as Child Development Services, Mid-Coast Children's Services, Mid-Coast Mental Health Center, or any other?
Yes
No
Clear selection
Has your child ever had any traumatic injuries, been to the emergency room, or been hospitalized?
*
Yes
No
Reason?
Your answer
Has your child had any medical problems requiring a physician's care during the past year?
*
Yes
No
Has your child ever been on medication for an extended period of time?
*
Yes
No
Medication Name
Your answer
Reason?
Your answer
Does your child take any medication now?
*
Yes
No
Medication Name
Your answer
Reason?
Your answer
Will it be necessary to take this medication during school hours?
Yes
No
Clear selection
Any other medical concern the school should be aware of?
Your answer
Family Health History (please check and indicate who, ie. mom, dad, maternal, paternal, grandparents, etc.)
Heart disease (before age 55)
Diabetes
Hypertension
Hearing problems/loss
Learning disabilities
None of the above
Other:
Does anyone in your immediate/extended family or close friend use drugs or alcohol in a way that concerns you or other family members?
Yes
No
Clear selection
Prenatal History - Were there any problems during your pregnancy with this child?
Yes
No
Clear selection
If 'yes', please explain.
Your answer
Any illness during your pregnancy?
Yes
No
Clear selection
If 'yes', please explain.
Your answer
Was there smoking/alcohol/drug use during pregnancy?
Yes
No
Clear selection
Was pregnancy full term?
Yes
No
Clear selection
Was labor and delivery normal?
Yes
No
Clear selection
Baby's birth weight
Your answer
Was there any injury/complication at the time of birth or during the first year?
Yes
No
Clear selection
Child received oxygen?
Yes
No
Clear selection
Did child leave the hospital with Mom?
Yes
No
Clear selection
Early Childhood History
As an infant this child was:
Average
Especially quiet
Overactive
Irritable
Feeding:
Normal
Problems
Sleeping:
Slept well
Slept restlessly
Hardly slept
If problems, please explain
Your answer
At what age did your child sit?
Your answer
At what age did your child walk?
Your answer
At what age did your child talk in words?
Your answer
At what age did your child talk in sentences?
Your answer
At what age did your child become toilet trained?
Your answer
Other significant milestones
Your answer
We know any child can occasionally have other problems. Please check if your child has frequently had difficulties with any of the following:
*
Nervous habits (thumb sucking, eye blinking, head banging, swaying/rocking, etc.)
Shyness
Nightmares
Crying easily
Fears (heights, dark, storms, snakes, etc.)
Temper tantrums
Physical complaints (stomach aches, headaches, etc.)
Agressiveness
Anger
Short attention span
None of the above
Other:
Required
Does your child get at least 10 hours of sleep at night?
Yes
No
Clear selection
Snore?
Yes
No
Clear selection
Still take a nap?
Yes
No
Clear selection
Eat a well balanced diet?
Yes
No
Clear selection
Take a vitamin/mineral supplement?
Yes
No
Clear selection
Normally eat breakfast?
Yes
No
Clear selection
Wear a seat belt?
Yes
No
Clear selection
Have you talked to your child about gun safety?
Yes
No
Clear selection
Do you have any questions/concerns about any health/school counseling issue as your child enters school?
Yes
No
If 'yes', please explain.
Your answer
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