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Health History Form

Health History Form

Please complete the form below. Required fields marked with an asterisk *

Student Name*

Answer required for "Student Name"

D.O.B*

Answer required for "D.O.B"

Gender*

Answer required for "Gender"

Address

Street Address*

Answer required for "Street Address"

City*

Answer required for "City"

State*

Answer required for "State"

Zip/Postal*

Answer required for "Zip/Postal"

Grade*

Answer required for "Grade"

Contact Information - Parent\Guardian

First Name*

Answer required for "First Name"

Middle Name

Answer required for "Middle Name"

Last Name*

Answer required for "Last Name"

Email 1*

Answer required for "Email 1"

Phone*

Number Required

Contact Information - Parent/Guardian

First Name

Answer required for "First Name"

Middle Name

Answer required for "Middle Name"

Last Name

Answer required for "Last Name"

Email 1

Answer required for "Email 1"

Email 2

Answer required for "Email 2"

Mobile Phone

Number Required

Home Phone

Number Required

Work Phone

Number Required

Complete the following information regarding your child's health. Give details and dates below

Answer required for "Complete the following information regarding your child's health. Give details and dates below"

ADD/ADHD

ALLERGIES

ALLERGY TO BEE STING

ASTHMA

BLADDER/KIDNEY PROBLEM

BLOOD DISORDER/ANEMIA

BONE/JOINT PROBLEMS

CANCER

CHICKEN POX

DIABETES

EMOTIONAL PROBLEMS

HEARING PROBLEMS

HEART PROBLEMS

HOSPITALIZATIONS

MEASLES

MIGRAINE HEADACHES

MUMPS

RESPIRATORY PROBLEMS

SCARLET FEVER

SEIZURE/EPILEPSY

SERIOUS ACCIDENT/INJURY

SERIOUS ILLNESS

SKIN PROBLEMS

SPEECH IMPAIRMENT

STOMACH PROBLEMS

SURGERY

VISION PROBLEMS/GLASSES

WHOOPING COUGH

Please provide information regarding checked boxes

Answer required for "Please provide information regarding checked boxes"

Please indicate any other medical issues not mentioned above

Answer required for "Please indicate any other medical issues not mentioned above"

Please list any medications taken by the child along with dosage and frequency

Answer required for "Please list any medications taken by the child along with dosage and frequency"

Family Doctor*

Answer required for "Family Doctor"

Hospital Preference*

Answer required for "Hospital Preference"

Signature*

Signature Required

Name: Date:

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Signature *

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Full Name *

Date:

Confirmation Email

Confirmation Email *

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1000 Lowry Ave, Jeannette, PA 15644 Phone: (724) 523-5497

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