ARMSTRONGSCHOOL DISTRICT

181 Heritage Park Drive –Suite 2

Kittanning, PA 16201-7025

STUDENT HEALTH HISTORY

Please complete the following health history for your child. If you do not wish to answer a particular question, simply leave it blank.

Student’s Name:______Sex: M_____F_____Birthdate:______

Male Guardian’s Name:______Relationship:______Year of Birth:______

Female Guardian’s Name:______Relationship:______Year of Birth:______

Student lives with: Both Parents___Mother___Father___Legal Guardian___Foster Parents___Group Home___

Brothers:______Birthdate:______Sisters:______Birthdate:______

______

______

  1. FAMILY HEALTH HISTORY
  1. Circle and describe any condition the student’s parents, grandparents, aunts, uncles, brothers or sisters have had: allergy, asthma, cancer, drug or alcohol addiction, diabetes, heart disease, depression, seizures, tuberculosis, sickle cell anemia, vision problem, hearing problem, learning problem, other inherited or family diseases (specify)

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  1. DEVELOPMENTAL HISTORY

1. Student’s Birth Weight:______Explain any problems or complications:______

______

2. List approximate age when student: Sat without support______Walked alone______

Spoke two or three words together______Toilet trained______

3. Menstrual History (Girls Only): Age of Onset______Problems/Medication:______

______

(OVER)

Revised 02/24/2010

TO BE COMPLETED BY PARENT

A. Medical History: List date of onset for ones that apply to your child.

_____Attention Deficit/ADHD_____Diabetes_____Skin Disorder

_____Arthritis_____Dietary Restrictions_____Speech Difficulty

_____Asthma triggers_____Eatting Disorder_____TB Exposure

_____allergies_____Fainting Spells_____Thyroid Condition

_____exercise_____Gastrointestinal Condition_____Vision Deficit

_____infection_____Headaches _____severe loss

_____weather_____Head Injury/Concussion _____eye surgery

_____Autoimmune Deficiency_____Hearing Deficit _____glasses/contacts

_____Bladder Control_____Heart Condition_____Other (Specify)______

_____Bleeding Disorder/Anemia_____High Blood Pressure______

_____Bowel Control_____Kidney Condition______

_____Chicken Pox_____Lung ConditionUse this space, if needed, to

_____vaccine_____Malignancyelaborate on any above

_____disease_____Neurological Disordercondition(s).

_____Cystic Fibrosis_____Neuromuscular Disorder______

_____Color Blindness_____Nosebleeds______

_____Connective Tissue Disorder_____Orthopedic Cond./Fractures______

_____Dental Condition_____Psychiatric Cond./Emotional______

_____Developmental Delay_____Seizures______

B. Allergies: foods______bees______drugs______plants/animals______other______

Please describe the allergic reaction and treatment: ______

______

______

C. Is medication needed for allergy:

At home? No______Yes_____Name of Medication______

At school? No_____Yes_____(If yes, please complete Form “Medication at School.”)

Does the student take any medication regularly? No_____Yes_____(Please list medication(s) and dosage(s):

______

D. List major operations, injuries, or hospitalizations. Give dates: ______

______

______

E. Last eye examination (date) ______by Dr. ______

Last dental examination (date) ______by Dr. ______

Last medical examination (date) ______by Dr. ______

F. Is there anything you can tell us about your child that you feel will help the school staff to better understand and work with him/her?______

______

______

I UNDERSTAND AND AGREE THAT ANY MEDICAL INFORMATION MAY BE SHARED WITH APROPRIATESCHOOL AND MEDICAL PERSONNEL.

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Signature of Parent/Guardian Relationship Date

Revised 02/24/2010