Microsoft word - health history-1.doc

Eufaula Public Schools
Health History

Student’s Name ________________________________ Date of Birth___________________Date _____________
SSN ___________________________________ Medicaid/SoonerCare # _________________________________
Student’s Address ______________________________________________________________________________
Street/Apt.
#
City/State
Zip
Code
Parent/Guardian _______________________________________________________________
Name
Home
#
Work
#
Cell
#
Parent/Guardian _______________________________________________________________
Name
Home
#
Work
#
Cell
#
Contact Person ________________________________________________________________
Name

Student’s Doctor _____________________________Phone # ____________________Last Seen _____________
Dentist _____________________________ Phone # _________________ ___Last Seen______________
Specialist _____________________________ Phone # ____________________Last Seen ______________
Health History: Please check any condition below that the student has had, past or present. Please explain condition below.
__Asthma
__Bowel/bladder/kidney
problems
__Hospitalizations
__ADD/ADHD
__Cancer __Lead
poisoning
__Autism __Cystic
fibrosis
__Seizure
disorder
__Behavior/emotional
concerns
__Diabetes
__Skin
conditions
__Birth/congenital
malformations
__Ear/hearing
problems
__Surgeries
__Bone/muscle/joint
problems
__Headaches
__Vision
problems
__Blood problems
__Heart problems
__Other __None

Allergies: __Life Threatening
Food _____________________________________ Insect ________________
__Seasonal
Medication:_________________________ Other: _______________________

List any prescription and over the counter medications your child takes on a regular basis. Will this medication
be taken while at school? *See Note Below
_____________________________________________________________________________________________________________________
The nurse keeps some over the counter (OTC) medications on hand for students with mild fever, headache, mild
pain, upset stomach, etc. Please check which of these you give permission for the nurse or school personnel to
administer to your child:
__Acetaminophen (e.g. Tylenol)
__Antacids (egg. Tums)
__Antibiotic Cream/Ointment
__Ibuprofen (e.g. Advil, Motrin)
__Antihistamine (egg. Benadryl)
__Hydrocortisone Cream
__Ointments/Creams for rashes (e.g. Calamine)
I understand that under state law the Board of Education, the School District, or employees of the district shall
not be liable to the student or the student’s parent or guardian for liability or civil damages for any personal
injuries to the student which result from administration of any of the above medications.
I give permission for release of information on this form for confidential use in meeting my child’s health and
educational needs in school.

Parent/Guardian Signature__________________________________________________Date________________
*Please note for your child to receive any other medication not listed on this paper, you must send the medication to school with the child as
well as a written consent for the nurse or school personnel to administer. Prescription medications should be in a container appropriately
labeled by the pharmacist or physician. OTC medications should be in their original containers. Medication in any other form will be
immediately returned. Medications taken on a regular basis will need a written authorization of a healthcare provider. Please see the school
nurse if you have any questions. Medication that is not reclaimed by the last official day of school will be destroyed according to school
policy.

Source: http://eufaula.k12.ok.us/HEALTH/pdf/Health%20History-1.pdf