RSU 13 Student Health History - South School
Note: Information shared with school personnel is at your discretion.
Student's Full Legal Name *
Your answer
Date of Birth *
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Street Address *
Your answer
Telephone Number *
Your answer
Mailing Address *
Your answer
People Living in Household *
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 *
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DD
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YYYY
Dentist's Name *
Your answer
Dentist's Address and Office Telephone Number *
Your answer
Date of Last Visit *
MM
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DD
/
YYYY
Has your child had: *
Required
Does your child have: *
Required
Handicapping condition? *
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? *
Has your child ever had any traumatic injuries, been to the emergency room, or been hospitalized? *
Reason?
Your answer
Has your child had any medical problems requiring a physician's care during the past year? *
Has your child ever been on medication for an extended period of time? *
Medication Name
Your answer
Reason?
Your answer
Does your child take any medication now? *
Medication Name
Your answer
Reason?
Your answer
Will it be necessary to take this medication during school hours?
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.) *
Required
Does anyone in your immediate/extended family or close friend use drugs or alcohol in a way that concerns you or other family members? *
Prenatal History - Were there any problems during your pregnancy with this child? *
If 'yes', please explain.
Your answer
Any illness during your pregnancy? *
If 'yes', please explain.
Your answer
Was there smoking/alcohol/drug use during pregnancy? *
Was pregnancy full term? *
Was labor and delivery normal? *
Baby's birth weight *
Your answer
Was there any injury/complication at the time of birth or during the first year? *
Child received oxygen? *
Did child leave the hospital with Mom? *
Early Childhood History
As an infant this child was: *
Required
Feeding: *
Required
Sleeping: *
Required
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: *
Required
Does your child get at least 10 hours of sleep at night? *
Snore? *
Still take a nap? *
Eat a well balanced diet? *
Take a vitamin/mineral supplement? *
Normally eat breakfast? *
Wear a seat belt? *
Have you talked to your child about gun safety? *
Do you have any questions/concerns about any health/school counseling issue as your child enters school? *
Required
If 'yes', please explain.
Your answer
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