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Health History Form

Please complete only if your child has a health condition. Completing the Health History Form below will prompt the school nurse to ensure appropriate supports are in place to help your child fully access their education.

Student & Parent Information

Student First Name *

This field is required

Student Last Name *

This field is required

Student Date of Birth *

This field is required

Current Grade *

This field is required

School *

This field is required

Parent/Guardian First Name *

This field is required

Parent/Guardian Last Name *

This field is required

Parent/Guardian Email *

This field is required

Parent/Guardian Phone *

This field is required

Health Conditions

Please select any conditions diagnosed by a doctor that apply to the student.

Allergies (Anaphylaxis)

Asthma

Heart Condition

Diabetes

Hemophilia

Juvenile Idiopathic Arthritis (JIA)

Nephrotic Syndrome

Seizure History

Other Health Conditions

Allergies (Anaphylaxis)

1. Substance causing allergic reaction?

Substance causing allergic reaction? is required

2. Age of diagnosis?

Age of diagnosis? is required

3. Is your child currently under a physician's care for this allergy?

YesNo

Is your child currently under a physician's care for this allergy? is required

4. How many allergic reactions has your child had?

How many allergic reactions has your child had? is required

5. Does your child need special meal accommodations at school?
(If yes, please also complete the 'Medical Statement to Request Special Meal Accommodations' form)

YesNo

Does your child need special meal accommodations at school?
(If yes, please also complete the 'Medical Statement to Request Special Meal Accommodations' form) is required

6. Which of the following symptoms has your child experienced?

Redness and swelling of faceCoughingGeneralized hivesBreathing difficultyDizziness or headachePale and/or clammyNauseaAbdominal cramps/diarrheaAgitation or skin flushingConvulsionsSevere itchingUnconsciousnessThrobbing heartbeat or throbbing in earsOther

Which of the following symptoms has your child experienced? is required

6a. Please specify other symptoms

Please specify other symptoms is required

7. Please describe the care/treatment/medications you provide during a reaction

Please describe the care/treatment/medications you provide during a reaction is required

8. Has your physician prescribed an EpiPen or other medication to be kept at school?
(If Yes, please also complete the 'Parent/Guardian and authorized health care provider request for medication' form)

YesNo

Has your physician prescribed an EpiPen or other medication to be kept at school?
(If Yes, please also complete the 'Parent/Guardian and authorized health care provider request for medication' form) is required

9. Has your physician prescribed an EpiPen or other medication to be kept at home?

YesNo

Has your physician prescribed an EpiPen or other medication to be kept at home? is required

10. Any specific locations or activities at school that should be restricted due to allergy risk?

YesNo

Any specific locations or activities at school that should be restricted due to allergy risk? is required

10a. If yes, please describe

If yes, please describe is required

11. Any other information about the student's allergic condition that the school staff should be aware of?

YesNo

Any other information about the student's allergic condition that the school staff should be aware of? is required

11a. Comments or Additional Information

Comments or Additional Information is required

Asthma Details

1. Has your child's asthma been diagnosed by a doctor?

YesNo

Has your child's asthma been diagnosed by a doctor? is required

2. Is your child currently under a doctor's care for asthma?

YesNo

Is your child currently under a doctor's care for asthma? is required

3. Age when asthma was first diagnosed:

Age when asthma was first diagnosed: is required

4. Which are your child's triggers?

GrassRespiratory infectionsPollensStrong EmotionsMoldPhysical activityHouse dust mitesWeather conditionsAnimalsFoodsPet DanderOthers

Which are your child's triggers? is required

5. Please describe your child's asthma:

Mild IntermittentMild PersistentModerate PersistentSevere Persistent

Please describe your child's asthma: is required

6. How often does your child experience cough, shortness of breath or wheezing?

Seldom1-2 times per month1-2 times per week3-5 times per weekDaily

How often does your child experience cough, shortness of breath or wheezing? is required

7. How often does your child wake at night coughing or wheezing?

Never1-2 times per month1-2 times per week3-5 times per weekDaily

How often does your child wake at night coughing or wheezing? is required

8. How often does your child miss school due to asthma?

NeverOccasionallyOften

How often does your child miss school due to asthma? is required

9. Has your doctor recommended any physical restrictions?
(If yes, please complete the Medical Clearance for School Participation form.)

YesNo

Has your doctor recommended any physical restrictions?
(If yes, please complete the Medical Clearance for School Participation form.) is required

9a. Explain physical restrictions

Explain physical restrictions is required

10. Number of visits to doctor's office for asthma in the past year:

Number of visits to doctor's office for asthma in the past year: is required

11. How many times has your child been hospitalized for asthma?

How many times has your child been hospitalized for asthma? is required

11a. How many times has your child visited the emergency room for asthma?

How many times has your child visited the emergency room for asthma? is required

12. Does your child receive nebulizer?

YesNo

Does your child receive nebulizer? is required

13. Is your child taking medication for asthma?
(If Yes, please also complete the 'Parent/Guardian and authorized health care provider request for medication' form)

YesNo

Is your child taking medication for asthma?
(If Yes, please also complete the 'Parent/Guardian and authorized health care provider request for medication' form) is required

13a. Medication(s):

Medication(s): is required

14. Comments or Additional Information

Comments or Additional Information is required

Diabetes Details

1. Age Diabetes Diagnosed:

Age Diabetes Diagnosed: is required

2. What Type of Diabetes:

What Type of Diabetes: is required

3. How is your chid's blood sugar monitored?

How is your chid's blood sugar monitored? is required

4. Does your child take insulin?

YesNo

Does your child take insulin? is required

4a. If yes, what is the method of delivery?

If yes, what is the method of delivery? is required

5. What does your child say/do when their sugar level is low?

What does your child say/do when their sugar level is low? is required

6. What does your child say/do when their sugar level is high?

What does your child say/do when their sugar level is high? is required

7. Does your child have emergency medications? If so, please list:

Does your child have emergency medications? If so, please list: is required

8. Does your child have a special diet?
(If yes, please also complete the 'Medical Statement to Request Special Meal Accommodations' form)

YesNo

Does your child have a special diet?
(If yes, please also complete the 'Medical Statement to Request Special Meal Accommodations' form) is required

9. Comments or Additional Information

Comments or Additional Information is required

Heart Condition Details

1. Age of diagnosis:

Age of diagnosis: is required

2. Is your child currently under the care of a cardiologist?

YesNo

Is your child currently under the care of a cardiologist? is required

2a. If yes, how frequently is he/she seen?

If yes, how frequently is he/she seen? is required

3. Type of heart condition:

MurmurArrhythmiasCoarctation of the AortaAtrial Septal Defect (ASD)Aortic Valve StenosisCongestive Heart FailurePatent Ductus Arteriosus (PDA)Tetralogy of FallotTransposition of the Great VesselsTruncus ArteriosusVentricular Septal Defect (VSD)OtherDo not know

Type of heart condition: is required

3a. Please specify other condition:

Please specify other condition: is required

4. Does your child have any of the following symptoms?

Shortness of BreathColor ChangeChest PainDizzinessFaintingIrregular heartbeatSwelling: Legs/AnklesFatigue or WeaknessOther

Does your child have any of the following symptoms? is required

4a. Please specify other symptoms:

Please specify other symptoms: is required

5. Has your child ever had surgery?

YesNo

Has your child ever had surgery? is required

5a. Age your child had surgery:

Age your child had surgery: is required

5b. What type of surgery?

What type of surgery? is required

6. Has your child ever been hospitalized for this condition?

YesNo

Has your child ever been hospitalized for this condition? is required

6a. If yes, please provide dates and details:

If yes, please provide dates and details: is required

7. Does your child have any physical limitations/restrictions or accommodations? (MD note required) If so, please describe and fill out the Medical Clearance for School Participation form.

Does your child have any physical limitations/restrictions or accommodations? (MD note required) If so, please describe and fill out the Medical Clearance for School Participation form. is required

8. Is your child taking medications? If so, what?

Is your child taking medications? If so, what? is required

9. Any other information about the student's heart condition that the school staff should be aware of?

YesNo

Any other information about the student's heart condition that the school staff should be aware of? is required

9a. Comments or Additional Information

Comments or Additional Information is required

Hemophilia Details

1. Age of diagnosis

Age of diagnosis is required

2. Type of hemophilia

Classic Hemophilia (factor VIII deficiency)Christmas Disease (factor IX deficiency)Von Willebrands (VW protein deficiency)

Type of hemophilia is required

3. Severity of hemophilia

MildModerateSevere

Severity of hemophilia is required

4. Type of replacement therapy?

Type of replacement therapy? is required

5. Can your child tell if they are having a joint or muscle bleed?

YesNo

Can your child tell if they are having a joint or muscle bleed? is required

6. Does your child wear protective equipment?

YesNo

Does your child wear protective equipment? is required

6a. If yes, type:

If yes, type: is required

7. Does your child have a central line?

YesNo

Does your child have a central line? is required

8. Describe activities that your child should not participate in:

Describe activities that your child should not participate in: is required

Treatment Center Information

9a. Name of treatment center

Name of treatment center is required

9b. Treatment center phone

Treatment center phone is required

10. Any other information about the child's bleeding disorder?

Any other information about the child's bleeding disorder? is required

10a. Comments or Additional Information

Comments or Additional Information is required

Juvenile Idiopathic Arthritis (JIA) Details

1. Age when JIA was diagnosed

Age when JIA was diagnosed is required

2. Joints and extremities that are involved

Joints and extremities that are involved is required

3. Last time symptoms were very severe

Last time symptoms were very severe is required

4. Is your child currently taking any JIA medication?

YesNo

Is your child currently taking any JIA medication? is required

4a. If yes, list medication/s, dose and time

If yes, list medication/s, dose and time is required

5. Has your child taken medication for JIA in the past?

YesNo

Has your child taken medication for JIA in the past? is required

5a. If yes, list medication(s).
If medications are needed to be taken at school, please complete Parent/Guardian and authorized health care provider request for medication.'

If yes, list medication(s).
If medications are needed to be taken at school, please complete Parent/Guardian and authorized health care provider request for medication.' is required

6. Type of JIA

Systemic JIAPolyarticular JIAOligoarticular JIA

Type of JIA is required

7. Does your child have any activity restrictions?

YesNo

Does your child have any activity restrictions? is required

7a. Explain

Explain is required

8. Comments or Additional Information

Comments or Additional Information is required

Nephrotic Syndrome Details

1. Age diagnosed with Nephrotic Syndrome?

Age diagnosed with Nephrotic Syndrome? is required

2. Dates of last relapses

Relapse #1

Date

Symptoms

Relapse #2

Date

Symptoms

Relapse #3

Date

Symptoms

Relapse #4

Date

Symptoms

3. Frequency of relapses per year?

Frequency of relapses per year? is required

4. Current medications

Medication #1

Name

Dose

Time

Medication #2

Name

Dose

Time

Medication #3

Name

Dose

Time

Medication #4

Name

Dose

Time

5. Does your child have a modified diet?
(If yes, please also complete the 'Medical Statement to Request Special Meal Accommodations' form)

YesNo

Does your child have a modified diet?
(If yes, please also complete the 'Medical Statement to Request Special Meal Accommodations' form) is required

6. Does your child have a fluid restriction? (Healthcare provider note needed)

YesNo

Does your child have a fluid restriction? (Healthcare provider note needed) is required

6a. If yes, what is your child's fluid limit?

If yes, what is your child's fluid limit? is required

6b. Does your child monitor fluid intake and output?

YesNo

Does your child monitor fluid intake and output? is required

7. Does your child monitor protein clearance with urine dipstick testing? (Healthcare provider note needed)

YesNo

Does your child monitor protein clearance with urine dipstick testing? (Healthcare provider note needed) is required

8. Does your child need to test his/her urine at school?

YesNo

Does your child need to test his/her urine at school? is required

9. Comments or Additional Information

Comments or Additional Information is required

Seizure History Details

1. Age of first seizure?

Age of first seizure? is required

2. How often do seizures occur?

How often do seizures occur? is required

3. Type of seizure?

Type of seizure? is required

4. Current medications

Current medications is required

5. Medication side effects?

Medication side effects? is required

6. Known seizure triggers?

Known seizure triggers? is required

7. Date of last seizure

Date of last seizure is required

8. Typical seizure duration (minutes)

Typical seizure duration (minutes) is required

9. Post-seizure behavior

Post-seizure behavior is required

10. Does the student have emergency medication?

YesNo

Does the student have emergency medication? is required

Emergency Medication

10a. Name of emergency medication

Name of emergency medication is required

10b. Instructions for emergency medication

Instructions for emergency medication is required

11. Any assistive devices used?

Any assistive devices used? is required

12. Is there a seizure action plan on file? (If yes, please provide a copy to the school nurse)

YesNo

Is there a seizure action plan on file? (If yes, please provide a copy to the school nurse) is required

13. Comments or Additional Information

Comments or Additional Information is required

Other Health Condition Details

1. Date of diagnosis: *

Date of diagnosis: is required

2. Diagnosis: *

Diagnosis: is required

3. Treatment given:

Treatment given: is required

4. Is the treatment current? *

YesNo

Is the treatment current? is required

5. Is your student being followed by an MD for this?

YesNo

Is your student being followed by an MD for this? is required

6. Current Medications:

Current Medications: is required

7. Any physical restriction or accommodations needed?

Any physical restriction or accommodations needed? is required

8. What symptoms does your student experience?

What symptoms does your student experience? is required

9. What constitutes an emergency?

What constitutes an emergency? is required

10. Comments or Additional Information

Comments or Additional Information is required

I certify that the information provided is accurate and complete *

This field is required

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