HEALTH HISTORY
The Brooklyn Schools
Student Last Name: *
Student First Name: *
Student Middle Name:
Student Date or Birth: *
MM
/
DD
/
YYYY
Student Address: *
Mother/Guardian Name: *
Father/Guardian Name: *
Names of siblings and their ages: *
1. With whom does the child live?: *
2. When did your child last have a physical exam or visit MD?: *
3. When did your child last have a dental exam?: *
4. Has your child had any accidents or operations since birth?: *
If yes, please explain:
5. Has your child had any of the following? Please check any that apply:
Please give dates and comment if needed on any you checked above:
6. Does your child have Asthma?: *
If yes, briefly describe frequency, symptoms and medications prescribed:
7. Does your child have an allergy to bee stings?: *
If yes, please check type of reaction:
Please describe treatment and medication to be given at school in case of bee sting reaction:
8. Does your child have any environmental, food or medication allergies?: *
If yes, please specify:
9. Does your child take medications on a daily basis?: *
If yes, specify medication and reason prescribed:
10. Does your child have any restrictions or any limitations on activity?: *
If yes, please explain:
11. Does your child have frequent ear infections?: *
12. Has your child had a hearing test?: *
If yes, date of test:
MM
/
DD
/
YYYY
Name of MD that administered hearing test:
Results of test:
13. Does your child have tubes in his/her ears?: *
If yes, date of insertion of tubes:
MM
/
DD
/
YYYY
14. Does your child wear glasses?: *
If yes, date of last exam:
MM
/
DD
/
YYYY
Results of exam:
15. Is bedwetting a problem?: *
Does your child have accidents during the day?: *
Does your child have occasional accidents with bowel movements?: *
16. Are there any concerns within the child´s living situation which might affect learning?:
17. Is there anything more about the child´s health that you think is important for us to know (eating, sleeping, weight concerns)?:
18. May we share this information with appropriate staff?: *
19. Does your child have health insurance?: *
If yes, please check which kind:
Name of Parent/Guardian filling out this form: *
Submit
Never submit passwords through Google Forms.
This form was created inside of Brooklyn Public Schools. Report Abuse