MERIDIAN SCHOOL DISTRICT

HEALTH HISTORY FOR SCHOOL YEAR 2014-2015

Name of child: ______Birth date:______Grade: ______

Last First Middle

Parent name: ______Email: ______

Home #______Cell#______Work#______Teacher______

Other schools attended:______

Current weight: ______Date of last tetanus (Td or Tdap)______

Date of last well-child exam: ______

DO YOU HAVE HEALTH INSURANCE? ___YES ___NO

DO YOU HAVE MEDICAL COUPONS? ___YES ___NO

Child’s physician ___NO ____YES--Name and Ph.#______

Child’s dentist ___NO ____YES--Name and Ph.#______

HEALTH CONCERNS/HEALTH HISTORY: (All information is confidential, reviewed by school nurse (RN), and is shared only with school staff that have a “need to know”.)

  Check here if there are NO known health problems

1. ALLERGIES circle one: medication food insect other 6. HEARING PROBLEM

Specify: ______ Yes/No

Diagnosed by physician Last exam: ______

Life threatening? Type of loss: ______

Epi pen required  Assistive device used: ______

Health plan in place:

*Needs medication at school 7. HEART PROBLEMS

 Type:______

2. BEHAVIORAL PROBLEMS  Plan needed?

Attention Deficit Disorder (ADD)

Attention Deficit/Hyperactivity (ADHD) 8. MOVEMENT PROBLEMS

Behavior or mood concerns? type ______ Type: ______

 School Plan needed?  Plan needed?

3. BREATHING/RESPIRATORY PROBLEMS 9. SEIZURE PROBLEMS

Asthma  Grand Mal

Exercise-induced asthma  Absence (petit mal)

*Needs medication at school  Complex

Other: ______ Other:______

 Plan needed

4. DIABETES *Medication taken/needed:

Type I (takes insulin)* ______

Type II (diet /medication control)

Note: School plan is required10. DENTAL PROBLEMS

List: ______

5. DIGESTION/ELIMINATION

Bowel control concerns/diarrhea 11. VISION PROBLEMS

Bladder problems Contact lenses

Constipation  Glasses for: ______

Other:______ Must wear glasses at school

Other: ______

Last eye exam:______

ANY OTHER PHYSICAL OR MENTAL HEALTH PROLEMS?

If so, please list: ______
______

NOTE: Any student with a life-threatening condition cannot attend school until all forms are in place.

ALL students must have written record of all required immunizations on file at Meridian school before they can start school.

* If student is to take any medicine at school, Authorization Form from medical provider, signed permission

form from parent/legal guardian, and medicineMUST be at school before medicine is given.

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I authorize Meridian School Districtstaff to give first aid and/or to contact emergency medical services for any emergency treatment necessary for my child. I understand that I assume full responsibility for payment of any services rendered. Every effort will be made to contact parent/guardian in the event of a non-life threatening emergency.

______

Signature of parent/legal guardian Date