HS/EHS Health History Form

Sex
Has child ever been hospitalized or operated on?
Has child ever had a serious accident (broken bones, head injury, falls or burns)?
Has child ever had a serious illness?
Does child have frequent:
Does child have frequent:
Is your child up to date on their immunizations?

Complete an Immunization Exemption Form if parents/guardians wish to not immunize.

Does child have difficulty seeing (squint, cross eyes, look closely at books or objects)?
Has your child had a vision exam by an eye doctor?
Were they prescribed glasses?
Is there any family history of
Was your child born before 32 weeks?
Docs your child have problems with ears/hearing (pain in ear, frequent earaches/infections, discharge, rubbing or favoring 1 ear, tubes)?
Is there any family history of deafness or any family that wears hearing aids?
Has child ever had a convulsion or seizure? (If yes complete Seizure Plan)
Is child taking other medicines now? (If yes, complete the Medication Permission and Record Form)
Is the child now being treated by a physician or dentist?
Has the child had any of the below?
Has the child had any of the below?
Does your child have any allergy problems?
If the child has allergies does it require the use of an Epi-pen? (Special consent must be signed and an epi pen must be left at the school)

Complete the Medication Permission and Record Form.

Do any of the conditions covered so far get in the way of the child's daily activities?
Could any concerns be life-threatening?
Has your child had their hemoglobin checked?
Results
If they have had a low level, were they placed on an iron supplement or recommended to add iron rich foods to their diet?
Are they still taking an iron supplement?
Has your child had their lead checked?
Results
Has your child had lead poisoning?
Is your child currently being treated for lead poisoning?
Does your child chew on unusual things? (Wood, pencils, paint chips, paper, clay, soil, cigarettes)
Does your child live in or regularly visit a house made before 1950?
Does your child use a car seat when in the car?
Does your home have working smoke and carbon monoxide detectors?
The source of water in your home is?
Does anyone smoke in the house/car when children are present?
Does your child receive WIC?
Would you like assistance in obtaining WIC?
Does your child's weight appear normal?
Do you have any concerns over your child's weight?
Is your child a picky eater?
Is your child involved in physical play daily?
Is you child having any dental problems that may affect their eating?
Does your child have difficulty chewing or swallowing now?
Is your child lactose intolerant?

Infants (6 weeks up to 1 year)

What is your child's feeding method?
Was this specially prescribed by your child's doctor? (Please provide prescription)
Has your child been introduced to baby food?
Have they had any reactions to food they've tried?

Toddlers (1 year to 3 years)

Does your child drink from a cup or sippy cup?
Does your child feed themselves with a spoon or fork?
Does your child eat fruit or vegetables daily?
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