Moon Area School District | Health History Form

Health History Form

Moon Area School District Health Services School Entrance Form

Student's Last Name *
Student's First Name *
Student's Grade Level
List the month and year child had chickenpox

If child never had the illness, please enter 'never.'
List month and year child had measles (9 day)

If child never had illness, enter 'never.'
List month and year child had rubella (3 day measles)

If child never had illness, enter 'never.'
List month and year child had rheumatic fever.

If child never had illness, enter 'never.'
List month and year child had pneumonia

If child never had illness, enter 'never.'
List month and year, child had another disease/illness that the district should note.

If child never had illness, enter 'never.'
If your child has been hospitalized for any illnesses, operations, fractures, etc., list the reasons along with the month and year
Hearing

Earaches

Tubes in ears

Hearing loss

Need for special seating in classroom

Use of hearing device

Check the conditions that pertain to your child (past or present)
If child has experienced hearing loss, please specify which ear(s).
Left earRight earBoth earsNo hearing loss
Vision

Wears glasses and/or contacts

Need for special seating in classroom

Other, describe below

Check the conditions that pertain to your child (past or present)
Other Medical Conditions

asthma/wheezing

heart conditions

seizures/convulsions

urinary concerns

skin conditions (eczema)

gastrointestinal conditions

menstrual difficulties

migraine headaches

ADD/ADHD

diagnosed learning disabilities

developmental delays

speech or language concerns

behavior (temper tantrums, fighting, etc.)

dental appliances

Use of braces, walkers, etc.

Other, describe below

Check the conditions that pertain to your child (past or present)
Explain any chronic or other health conditions noted above:
List food allergies:

Please provide a physician order for dairy allergies/intolerance.
List medication allergies:
List any other allergies:

(i.e., bee stings, insects, other substances)
List environmental allergies:

(i.e., hayfever, ragweed, etc.)
Treatment/medication for above listed allergies:

•Medications: Refer to the Moon Area School District Medication Policy. Contact the School Nurse at your child’s school if the child requires medications to be given during the school day. A Doctor’s order must accompany all medications along with written parental consent. Emergency medications should be available for the 1st day of school.
Is your child presently under a Doctor’s care for a specific health condition? If yes, name doctor and reason.
Is your child presently taking any medication? List the name and reason for the medicine, along with start/stop date:
Is your child restricted from any physical activities in gym or recess as recommended by a physician?

If yes, explain and provide physician doccumentation to school nurse.
Note any other information about your child/family situation that you feel necessary for the School Nurse/Teacher to know to help assist your child to receive maximum benefits from education.
Would you like to set an appointment with the school nurse?

yes

no
Name of parent/guardian *
Parent/guardian phone number *
Date Form Completed *