WHITE BEAR LAKE AREA SCHOOLS Independent School District #624
HEALTH HISTORY, DEVELOPMENTAL, AND FAMILY FACTORS
GENERAL INFORMATION
Child’s name______Sex______Birthdate______
Parent/Guardian______School child will attend ______
Address______
Home phone______Work/cell phone______
Other parent’s name and address (if different from above) ______
Home Language ______CHILD’S DOCTOR OR CLINIC______
DATE of last physical examination ______DIAGNOSIS______
Do You Have Health Insurance? Yes / No Name of Provider______
Past or present services from: Public health nurse Home care WIC/MAC Other
Dentist______Date of last examination ______
Optometrist or ophthalmologist______Date of examination______
Is your child attending: Day care Preschool Head Start ECFE Other
Attending where and how often? ______
Have you participated in Early Childhood Family Education classes? Yes / No
PAST MEDICAL HISTORY
PREGNANCY AND BIRTH
Yes No Was child adopted? If YES, at what age? ______
Yes No Did child’s mother have difficulties during labor and/or delivery?
Describe ______
Yes No Did your child weigh less than 5 pounds? Child’s actual birth weight ______
Yes No Did your child stay in the hospital after mother was discharged?
If yes, please explain ______
Yes No Did your child pass their newborn hearing screening?
GROWTH AND DEVELOPMENT
AGE YOUR CHILD DID THE FOLLOWING:
______Babble and coo ______Walks alone
______Sit with support ______Beginning to talk
______Stand with support ______Toilet trained
Do you think your child should be doing more than he/she is doing for his/her age? Yes / No
If YES, explain ______
CHILDHOOD ILLNESSES
HAS YOUR CHILD HAD ANY OF THE FOLLOWING DISEASES?
Yes No Chicken Pox Yes No Pneumonia
Yes No German or 3-Day Measles Yes No Red or Hard Measles (Rubella)
Yes No High Fever (104o - longer than 2 days) Yes No Rheumatic Fever
Yes No Meningitis Yes No Scarlet Fever
Yes No Mumps Yes No Strep Infections
Yes No Was your child ever hospitalized? If YES, when and why? ______
______
Yes No Has your child had other important illnesses in which he/she was not hospitalized?
If Yes, what and when? ______
SPECIAL HEALTH CARE
Yes No Does your child have any physical limitations or restrictions? If yes, what? ______
______
Yes No Has your child ever undergone any special tests for health problems? If yes, what? ______
______
Yes No Is your child taking medication regularly? If yes, what? ______
______
ALLERGIES
Yes No Has your child ever had problems with allergic reactions to foods, airborne pollens, insects, or
medications? If yes, what? ______
Yes No Does your child take any medications related to the allergies? If yes, what?______
______
ACCIDENTS
Yes No Has your child ever had any serious accidents or injuries? Describe ______
______
Yes No Does your child have frequent accidents? Describe ______
______
Yes No Has your child ever become poisoned? Describe ______
SAFETY PRACTICES
Yes No Do you know Poison Control Access phone numbers?
Yes No Do you use car seats/seat belts?
Yes No Do you have smoke detectors in place and are they working?
MEDICAL/COUNSELING/THERAPY SERVICES
Is your child/family receiving services from the following or have they in the past? If yes, please give information where specified.
Yes No Medical Specialist
Yes No Occupation, Physical, or Speech Therapist
Yes No Social Worker, Case Manager, Psychologist/Counselor
Yes No Is your family participating in a group? Type of Group:______
FAMILY HISTORY (Circle all that apply)
Allergy or hay fever Deafness Heart problems Mental disorders Reading problems
Asthma Diabetes Hemophilia Cognitive Delays Rheumatic fever
Cancer Epilepsy Muscular dystrophy Sickle cell anemia Hepatitis
Cleft lip or palate Eye abnormalities Other blood disorders Thalassemia
Cystic fibrosis Growth problems High blood pressure Other family diseases Tuberculosis
Are there other family members who have had the same or similar physical/developmental concerns? Yes No
Are there other children in your family who may have developmental problems? Yes No
PRESENT HEALTH
NUTRITION/SLEEP/ENERGY
Yes No Do you have concerns about your child’s nutrition/eating habits?
Yes No Does your child have excessive thirst?
Yes No Does your child have a sleep problem?
Yes No Does your child have too much or too little energy? Which? ______
Yes No Does your child have food allergies? If yes, what?______
Yes No Does your child take a vitamin/mineral supplement? If yes, what?______
Yes No Does your child have a normal appetite? If no, has it changed recently or has it always been this way?
______
Yes No Is your child on a special diet? What? ______
Yes No Do you have any concerns regarding your child’s eating habits or diet? If yes, what?______
______
How many meals does your child eat per day?______Snacks per day? ______
SKIN
Yes No Does your child have problems with hives, rashes, or eczema?
Yes No Does your child bruise easily?
Yes No Does your child have any unexplained lumps or spots?
EYES/EARS/NOSE/THROAT/DENTAL
Yes No Does your child have any problems with his/her eyes?
Yes No Has your child had 2-3 episodes of ear problems in a year?
Yes No Has your child had an earache or discharge form the ears within the past 6 months?
Yes No Does your child seem to have any trouble hearing?
Yes No Has your child ever had PE tubes in his/her ears?
Yes No Has your child had 2 or more throat infections in a year?
Yes No Does your child have frequent nose bleeds?
Yes No Does your child get swollen glands frequently?
Yes No Does your child have trouble with teeth, gums, or mouth?
RESPIRATORY
Yes No Has your child had 6-8 colds in a year?
Yes No Does your child get a severe cough with colds?
Yes No Does your child have trouble getting rid of a severe cough?
Yes No Does your child have shortness of breath at times, asthma, or wheezing problems?
CARDIOVASCULAR
Yes No Does your child have heart trouble?
Yes No Does your child have a known heart murmur?
GASTROINTESTINAL
Does your child have frequent:
Yes No Stomach aches Yes No Constipation
Yes No Diarrhea Yes No Vomiting
URINARY
Yes No Do you have any concerns about your child’s toileting?
Yes No Does your child’s urine have a strong or unusual odor?
Yes No Has your child ever had kidney or bladder problems?
SKELETAL
Yes No Does your child complain of pains in his/her legs, arms, back or joints?
Yes No Has your child had any broken bones, cast, brace, or corrective shoes?
Yes No Does your child toe in, toe out, limp, or walk with difficulty?
NEUROMUSCULAR
Yes No Does your child lose his/her balance in unusual ways?
Yes No Does your child have any unexplained movements or jerks, staring spells, seizures, falls, or weakness?
LEAD
Yes No Has your child ever been tested for lead? Where and results?______
Yes No Do you live or have you lived in a house or apartment built before 1960?
Yes No Has your house or apartment recently been painted, sanded, or had paint removed?
Yes No Does your child try to eat non-food items (examples: dirt, tobacco, pencils, etc)
PARENT COMMENTS
- Things about raising my child that are challenging:
- I would like my child to learn or get better at:
- When I need help with my family, I:
- Has any member of your family witnessed or experienced family or neighborhood violence? If YES, explain:
- Has there been unusual stress in your family that might affect your child? (Examples: new sibling, divorce, death of a family member, moving, financial problems, not enough food for family, etc.)
Any additional concerns/ information you would like to discuss:
Updated Aug 2017