Child’s name                                                                               DOB                                                
The following questionnaire is designed to help us get a better picture of your child, so that we can meet his/her needs in school.

Family Health History (parents, grandparents, siblings)

Tuberculosis                                                          Allergies                                                        
Insect/bee allergy                                                  Reaction                                                         Diabetes                                                                Scoliosis                                                        
Vision problems                                                    Color vision                                                  
Hearing problems                                                  Learning disabilities                                      
Other                                                                                                                                          

Child’s Health History

Birth weight                                                           Any congenital defects                                  
Drug / alcohol use during pregnancy                                                                                          
Allergies                                                                Symptoms                                                     
Has child ever been stung by a bee?                      Reaction                                                        
Accidents                                                                                                                                    
Hospitalizations                                                                                                                          
Operations                                                                                                                                   Seizures                                                                 Migraines                                                      
Ear infections                                                        Sore throats/tonsillitis                                  
Diabetes                                                                Digestive disorder (colitis, crohn’s)              
Eating disorder                                                      Heart problems                                             
Kidney Problems                                                   High blood pressure                                      
Pneumonia                                                            Asthma or breathing problems                      
Severe menstrual cramps                                       Bleeding disorder                                          
Anemia                                                                  Mono                                                            
Rheumatic Fever                                                   Scarlet Fever                                                 
Tuberculosis                                                          Contact with TB                                            Other                                                                                                                                          

Medications
Daily                                                                                                                                           
Occasionally                                                                                                                               

Hearing/Vision

Has your child ever seen a hearing/ear specialist? ____________________________________
Do you suspect a hearing problem?                                                                                            
Has your child ever seen an eye doctor?                                                                                     
Do you suspect a vision problem (including color vision)?                                                         
Does your child wear glasses or contacts?                                                                                  

Do any of these apply to your child?
Tires easily                                                            Extremely active                                           
ADD / ADHD diagnosis                                                                                                            
Problem with wetting or bowel soiling                                                                                        
Problem with eating or food intolerance                                                                                     

Family Life
Recent change in family dynamics                                                                                              
Has there been a death of a family member or close friend?
When?                                                                   Who?                                                             

Health care providers
Pediatrician                                                           Phone                                                            
Dentist                                                                  Phone                                                            
Preferred emergency room                                                                                                          

Parental PermissionThe School Nurse has my permission to share any information on this summary with other staff members who work with my child.

Parent Signature                                                       Date                                                                      

HR1

(revised 11/18/2005)