Jewell School District No.8

JEWELL SCHOOL DISTRICT NO.8

STUDENT HEALTH HISTORY

Student’s Name DOB: Grade Date ______

address ______

Street City State Zip

PARENT/GUARDIAN NAME ______

HOME PHONE ______CELL PHONE ______WORK PHONE ______

EMERGENCY CONTACT INFORMATION:

Contact # 1 Name/Phone/Relationship ______

Name Phone Relationship

Contact #2 Name/Phone/Relationship ______

Name Phone Relationship

Physician/ PCP to be called in an emergency ______

Name Phone

Notice: This information will become part of your student’s educational record and may be shared with appropriate school personnel for educational or safety purposes.

Please check any health concerns that apply provide as much detail as possible

Allergies (SPECIFY ALLERGENS):If YES please complete the additional Allergy Assessment Form

Severe allergic reaction ______Describe reaction______

Bee/insect sting: Describe reaction

MedicationDescribe reaction

FoodDescribe reaction

EnvironmentalDescribe reaction

Asthma: If YES Please completed additional Asthma Questionnaire(Yearly updated plan of care)

What starts an attack? exercisecolds allergies

smokeother

List asthma medications

SKIN CONDITIONS: ______

Attention Deficit Disorder (ADD/ADHD): treatment

Emotional/Behavioral Concerns:

Diagnosis: ______treatment

Diabetesinsulin dependentnon-insulin dependent: (Yearly updated plan of care)

Eating/Digestion Problems

Kidney/Bladder Problems

Heart Problems

Muscle/Joint/Bone Problems

Vision:contactsglassesvision losscolor blind other

Date of Last Exam

Hearing:hearing loss, describe

frequent ear infectionstubes in ears, which ear?age

speech therapyhearing aids

Headaches/Migraines: frequencytreatment

Head Injury: dateseverity

Please see reverse side for additional information and signature.

Seizures: If YES please complete the additional Seizure Disorder & Emergency Treatment Form (Quarterly updated plan of care)

typefrequencymedication

Past Surgeries

Past Major Illness/Injury

Medications:taken at home

taken at school

POSSIBLE EMERGENCY SYMPTOMS (child’s appearance or behavior)

______

______

Other medical conditions or limiting physical disorders

______

Siblings Living at Home:

Name Age Grade Name Age Grade

Please note: if you have indicated that your child has a special health concern we may ask for additional detailed information. this will help us make and individualized protocol in the event of an emergency. please ask the office if additional paperwork is indicated.

*I HEARBY GIVE PERMISSION FOR MY CHILD TO RECEIVE MEDICAL CARE, AND INFORMATION ON THIS DOCUMENT MAY BE MADE AVAILABLE TO SCHOOL, HEALTHCARE AND THE DEPARTMENT AUTHORITIES. Teachers will be made aware of health conditions. I also give my permission for nurse or nurse designee to contact the Physician/Dentist, if necessary regarding the medication(s) or health concerns.

parent signature ______Date______

Health Hx004/17