St. Aloysius Catholic School Ohioschool Health History (To Be Completed by Parent Or Guardian)

St. Aloysius Catholic School OhioSchool Health History (to be completed by parent or guardian)

Child’s Full Name ______Male______Female______

Last First Middle

Date of Birth______

Child’s Address______Phone______

With whom does your child live?______

Name Relationship

Who is this child’s legal guardian? ______

Name

Father’s Name______

Address (if different from child)______

Home Phone______Occupation______Work Phone______

Mother’s Name______

Address (if different from child)______

Home Phone______Occupation______Work Phone______

Family History:

Please list this child’s brothers and sisters

NameBirth YearSexNameBirth YearSex

1. ______4. ______

2. ______5. ______

3. ______6. ______

Is any language other than English spoken in the home? If so, what language? ______

Has this child attended play class/preschool? ______Where? ______

Has your child had speech therapy? ______Where? ______

Perinatal History:

Did the mother have and unusual or emotional illness during this pregnancy? ______yes ______no

If yes, explain briefly: ______

How old was the mother when the child was born?______Was the infant? ____ full term _____ early _____ late

Did this child as an infant have any sickness or problems? _____ yes_____ no

If yes, explain briefly: ______

Developmental History:

* Please give the approximate age at which this child:

______Walked alone ______Spoke in sentences ______Toilet Trained ______Dressed self

* How does this child’s development compare to other children, such as a brothers/sister or playmates?

______About the same ______Delayed ______Advanced

Behavioral History:

* The child is usually: ______Very active______Normally active______Rather inactive

* Has your child ever been violent or acted out in the following manner towards adults or other children?

______Hitting ______Kicking ______Biting ______Fighting ______Scratching

* Do you have any concerns about how your child gets along with other children? ______Yes______No

If yes, explain briefly: ______

* Is this student enrolled in special education courses? ______yes ______no

* Please add any comments or concerns you have about your child’s health, development, behavior, family, or home life that you would like the school to be aware of: ______

______

IMMUNIZATION RECORD

TypeDates

DTP, DT, DTaP___/___/______/___/______/___/______/___/______/___/___

Polio, OPV, or IVP___/___/______/___/______/___/______/___/______/___/___

MMR (combined)___/___/______/___/___

Hepatitis B (3) ___/___/______/___/______/___/___

HIB (not required) ___/___/______/___/______/___/___

Varivax (Chicken Pox) ___/___/___

Other (Identify)______/___/___

______

HEALTH CONDITIONS

Please check any that this child has had:

__ Abnormal spinal curvature (Scoliosis) __ Heart disease, type ______

__ Allergies of hay fever __ Hepatitis

__ Anemia __ Kidney disease, type ______

__ Arthritis__ Meningitis or encephalitis

__ Asthma or wheezing __ Multiple ear infections (3 or more)

__ Bedwetting at night __ Mumps

__ Behavior problem __ Near drowning or near suffocation

__ Birth or congenital malformation __ Nervous twitches or ticks

__ Cancer, type ______Poisoning

__ Chicken pox __ Poor hearing

__ Chronic diarrhea or constipation __ Pregnancy

__ Color blindness in family __ Rheumatic fever

__ Concern about relationship with siblings or friends__ Seizures or epilepsy

__ Cystic fibrosis __ Sickle cell disease

__ Diabetes __ Stool soiling

__ Eczema __ Substance abuse (alcohol, drugs)

__ Emotional problems __ Suicide attempt

__ Frequent headaches __ Urinary tract infection

__ Frequent skin infections __ Wears glasses

__ Frequent sore throat infections __ Wetting during day

______

ALLERGIES –

Medicines/drugs ______

If so, describe Reaction: ______

Foods/plants/animals/other ______

If so, describe Reaction: ______

MEDICATIONS-

Is the child on any medication?

Name/Dosage ______Reason ______

Name/Dosage ______Reason ______

Name/Dosage ______Reason ______

Name/Dosage ______Reason ______

Do you have any other comments or concerns about your child that you would like the school to be aware of?

______

______

INJURIES AND ILLNESSES

Injury/Illness Age Hospitalized?

______

______

______

Completed by ______

Name Relationship