diabetes. other (explain) 3. Check If your child has had any of the following: serious burn Diabetes. Convulsions. Sickle Cell. High blood pressure. Heart …
NORTH LITTLE ROCK SCHOOL DISTRICT
MEDICAL HISTORY FORM
|Date | | |Medicaid | |
| | | |Number | |
| |
|Name of | |Birthdat| |Sex | |Race | |
|Student | |e | | | | | |
| |
|Address| |Home Phone | |
| |
|Fathers | |Business | |
|Name | |Phone | |
| |
|Mothers | |Business | |
|Name |
|Phone | |
| |
|Students Doctor or| |Dentis| |
|Clinic | |t | |
| |
|Hospital | |
|Preference | |
| |
|PAST MEDICAL HISTORY |
| |
|1 Has your child had to stay in the | |Yes | | |No | | |
|hospital overnight? | | | | | | | |
| |
|If yes, for what |
|
|reason? | |
| |
|2 Check which of the following illnesses your| |
|child has had: | |
| | | | | | | | | | |
| | |measles | | |mumps | | |chicken pox | |
| | |strept throat | | |dehydration | | |bladder/kidney | |
| | | | | | | | |problems | |
| | |ear infections | | |convulsions | | |asthma | |
| | |pneumonia | | |bronchitis | | |frequent/constant | |
| | | | | | | | |colds | |
| | |epilepsy | | |tonsillitis | | |meningitis/encepha| |
| | | | | | | | |litis | |
| | |sustained high | | |allergic | | |rashes
| |
| | |fever | | |reaction | | | | |
| | |high blood | | |diabetes | | |other | |
| | |pressure | | | | | |explain | |
| | |
| |
|3 Check If your child has had any of the following: |
| |
| | |serious burn | | |near | |
| | | | | |drowning | |
| | |poisoning | | |bee sting | |
| | |broken bones | | |auto | |
| | | | | |accident | |
| | |cuts needing | | |surgery | |
| | |doctors care |
| | | |
| | |other | | | | | |
| | |explain | | | |Type | |
| | | | | | |
| |
|PRESENT MEDICAL HISTORY |
| |
|1 State any health concerns you have at this | |
|time about your child: | |
| |
| |
| |
| |
| |
|2 Does
your child have any | | |No | | |If yes, to what is | |
|allergies? Yes | | | | | |he/she allergic? | |
| |
| |
|Is your child | |eating problems?|Yes | | |No | | |
|experiencing: | | | | | | | | |
| | |sleeping |Yes | | |No | | |
| | |problems? | | | | | | |
| | |vision problems?|Yes | | |No | | |
| | |hearing |Yes | | |No | | |
| | |problems? | | | | | | |
| | |activity |Yes | | |No | | |
| | |limitations? | | | | | | |
| | | | | |
| | |
|OVER - COMPLETE BOTH SIDES |
|4 Does your child wear glasses or |Yes | | |No | | |
|contacts? | | | | | | |
| If yes, is he/she supposed to wear them|Yes | | |No | | |
|constantly? | | | | | | |
| If no, when is he/she to| |
|wear them? | |
| |
| When was he/she last seen by the| |
|eye doctor? | |
| |
|5 Is your child on any |Yes | | |No | | |If yes, what medication and| |
|medication? | | | | | | |for what? | |
|
|
| |
| |
|6 When did your child last see| |For what | |
|the doctor? | |reason? | |
| |
| |
| |
|7 Have any members of your childs immediate family brothers, sisters, parents, |
|grandparents, aunts, uncles |
|had any of the following: Check problem and list person who had it |
| |
|Example: X Heart disease grandmother |
|
|
| |Diabetes | | | |Convulsions | |
| |Sickle Cell| | | |High blood | |
| | | | | |pressure | |
| |Heart | | | |Cancer | |
| |disease | | | | | |
| | | | | | Type of | |
| | | | | |Cancer | |
| |
|8 If there is any thing the school nurse needs to know about your child that will |
|help her in providing health |
|services for him/her, please list it below |
| |
| |
|
|
| |
| |
| |
SCHOOL EMERGENCY MEDICAL AUTHORIZATION
If the above named pupil becomes seriously ill or injured at school and the
family cannot be reached immediately for provision of instructions, I
hereby authorize school personnel to call and/or arrange for transportation
of the pupil to our family physician
If this physician or dentist is not available, it is understood that the
school will call a doctor and/or will send the pupil, if necessary, to the
nearest facility for emergency care
It is understood, further, that I will pay for any emergency transportation
and for any subsequent emergency care, unless the costs are otherwise
covered by insurance
NOTE: Parents are responsible for notifying the school about any change of
information contained on this form
|Date:| |Signed:| |
| | | |Parent
or Guardian |
| |
|Please list the names of two people to be contacted in an emergency if the parents |
|cannot be reached |
| |
|Name | |Telephone | |
| | | | |
|Address| |Relation to | |
| | |Child | |
| | | | |
|Name | |Telephone | |
| | | | |
|Address| |Relation to | |
| | |Child |
|
Source:medschool.northwestern.edu
