PERKINS SCHOOL FOR THE BLIND
HEALTH SERVICES
STUDENT HEALTH HISTORY
Admission Health History
Student Name D.O.B.
Cause of Disabilities:
Health Problem List:
Allergies Please list allergies and reactions.
1. Drugs:
2. Food:
3. Environmental:
4. Has this student been prescribed an Epi-Pen? Yes/No If yes, for what allergy?
Birth History
Birth Weight Pregnancy term Type of delivery
Problems during or after birth?
Developmental Milestones Please specify at what age the following occurred or not at all:
Sitting alone Holding cup/toy/bottle independently
Walking alone Feeding self Toilet trained
First words Simple sentences or phrases
Past Health Problems
Hospitalizations
Surgeries
Chronic or recurrent problems
Vision
q Blind R L Both q Light Perception R L Both q Low Vision R L Both
Visual Acuity R: L:
Wears eyeglasses q yes q no Eye Prosthesis R L Both
Cause of Vision Loss:
Hearing
ÿ Within Normal Limits q Hearing Loss R L Both
Degree of Hearing Loss: q Mild q Moderate q Severe q Profound
Describe Hearing Aids or Devices:
Cause of Hearing Loss:
Implanted Devices (cochlear implant, shunt, spinal rod, g-tube, vagus nerve stimulator, other)
Type of Device Date implanted Most recent revision or replacement
Student Name Date of Review
Asthma or Reactive Airway Disease q yes q no
What are the asthma triggers?
What are the usual symptoms?
What is the usual treatment for wheezing episode for this student?
Does the student have an Asthma Care Plan? q yes q no **If yes, please attach.**
Seizure Disorder q yes q no
How often does this student have seizures?
When was the last seizure?
What do the seizures usually look like?
Is there any warning or behavioral change prior to seizure onset?
What is usual behavior after the seizure?
Are there safety concerns?
What is usual length of seizure?
How are the seizures managed:
Does student have Diastat or other recovery medication order? q yes q no if yes what med:
Diabetes q yes q no q Type 1 q Type 2 q Pre-Diabetes
Describe management:
Nutritional, Eating or Swallowing Disorder q yes q no, if yes please describe:
Requires special diet, food textures or fluid consistencies:
G-tube q yes q no, If yes, describe use of g-tube
Physical, Motor and Mobility Disorder q yes q no, if yes please describe:
Does the student require use of a wheelchair, stroller, walker or other mobility device?
Does the student wear braces or splits?
Does the student require assistance with transfers?
Other problems:
Mental Health Disorder q yes q no, if yes please describe
Diagnosis:
Hospitalizations:
Psychiatric Management:
Student Name Date of Review
Primary Care Physician (pediatrician)
Name
Address
Telephone# Fax #
Other Medical History and Conditions
Check off below all that apply and provide details
Yes / Condition / Details / Medical SpecialistContact Information
Genetic Syndrome
Cerebral Palsy
Orthopedic Disorder
Neurological Disorder
Developmental Disorder
Behavioral Disorder
Sleep Disorder
Cardiac Disorder
Respiratory/Pulmonary Disorder
Endocrine Disorder
Gastrointestinal Disorder
Metabolic Disorder
Ear/Nose/Throat Impairment or Chronic Infection
Other Chronic Medical Conditions:
______
Student Name Date of Review
Are there other health issues that impact education and/or residential care, please describe
Significant Family History Please circle response. If yes, please indicate relation to student.
Does anyone in your family have:
1. Epilepsy or seizures Yes No Relation:
2. Hypertension or stroke Yes No Relation:
3. Cardiac disease or death before age 50 Yes No Relation:
4. Autoimmune disorders Yes No Relation:
5. Allergies or Asthma Yes No Relation:
6. Diabetes Yes No Relation:
7. Genetic disorders Yes No Relation:
8. Learning disorders Yes No Relation:
9. Psychiatric illness Yes No Relation:
10. Reaction to anesthesia Yes No Relation:
11. High cholesterol Yes No Relation:
12. Cancer Yes No Relation:
Household members
Please list name and age of all persons student lives with in home.
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PERKINS SCHOOL FOR THE BLIND
HEALTH SERVICES
STUDENT HEALTH HISTORY
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PERKINS SCHOOL FOR THE BLIND
HEALTH SERVICES
STUDENT HEALTH HISTORY
Are there any pets at home? q Yes q No If yes, what?
Does anyone smoke in the home? q Yes q No
Current Medications
Medication Name / Condition Prescribed ForOther Comments
Parent Signature Date
Reviewed by Primary Care Physician: Signature Date
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