HEALTH HISTORY
Student Name: M F Date of Birth:
Child lives with: Number of children in family: This child is number:
PRENATAL, LABOR, DELIVERY & DEVELOPMENTAL HISTORY:
How did mother feel during pregnancy? Month of first doctor visit:
Any medication during pregnancy? Yes No What type?
Any of the following during pregnancy? Tobacco Alcohol Drugs Type:
Mother’s age during pregnancy: Father’s age during pregnancy:
Complications during pregnancy:
Delivery: Normal Difficult Cesarean (planned) Cesarean (emergency)
Complications during labor or delivery (difficulty breathing, oxygen used, etc.):
Birth weight: lb. oz. How long did baby stay in hospital?
Did baby have any problems during first month after birth? Yes No Explain:
Feeding history (difficulty gaining weight, allergies)?
Give approximate age when child:
Crawled Walked Put 3-4 words together Was potty trained
MEDICAL HISTORY (please check if your child has had any of the following):
Accidents Dental Emotional Heart Disease Sleep Problems
ADHD Diabetes Eye Problems Hospitalizations Surgeries
Allergies (type) Digestive Problems Broken Bones Meningitis Urinary Problems
Asthma Ear Infections Growth Concerns Seizures Other Bone/Joint Problems Eating Problems Head Injuries Skin Problems
Please describe any condition checked above:
BEHAVIOR HISTORY (please check those that apply):
Aggressive behavior Bed-wetting Destructive Extreme shyness Temper tantrums Thumb-sucking
Other: (if box is checked, please explain):
FAMILY HISTORY: Is there any one in the family who had difficulty in school (please describe):
PRESENT HEALTH STATUS:
PHYSICAL: Date of last physical exam: Doctor:
Is your child under a doctor’s care now? Yes No If yes, for what condition:
Is your child taking medication regularly? Yes No If yes, complete the following:
Name of medication: Amount of dose: Dr.:
Name of medication: Amount of dose: Dr.:
Type of medical insurance:
DENTAL: Date of last dentist visit: Dentist:
VISION: Date of last eye exam: Doctor:
Does your child wear glasses: Yes No If yes, when are glasses to be worn?
Are there any other factors that you feel the school should be aware of?
Parent / Guardian Signature: Date:
Atwater Elementary School District
Health History-English/cmc/mw/02/01/07