New Entrant Health History form

  • Printable version of New Entrant Health History form available here.

    Name of student:??????  School entering:??????  Grade:??????

    Date of Birth:??????  Gender (male/female):??????

    Address:??????  Home phone:??????

    Mother (or legal guardian):??????

    Father (or legal guardian):??????

    Student's dominant language:??????  Second language:??????

    Last school attended, if in New York State (name, address, & phone number):??????

    Prenatal & birth history (please describe any unusual events or secial treatment required during pregnancy, labor, delivery, or hospital stay):??????

    Early development history (please include any information about physical growth concerns, health problems or developmental delays):??????

    Medical history  Date of last physical exam:??????  Results:??????  Health Care Provider's name and phone number:??????

    Does your child take prescription or non-prescription medication???????  If yes, please indicate name of medication, dosage and time taken:??????

    If your child needs to take medication while at school, please complete the appropriate medication forms available at Central Registration or from you school nurse.

    Any allergies to:

    1. Food????
    2. Insect Stings????
    3. Pollens????
    4. Dust????
    5. Grass????
    6. Animals????

    Please complete the pink allergy questionnaire available at Central Registration or from your School Nurse.

    Any history of speech or language problems???????

    1. Hearing problems???????
    2. Vision problems???????

    Has your child ever received services from:

    1. Physcial therapist????
    2. Occupational therapist????
    3. Speech pathologist????
    4. Psychologist counseling????

    If yes, please explain:??????

Illness and Injuries list
  • Additional medical history:▁▁▁▁▁▁

    I understand that this confidential infomration will be shared with the school personnel as deemed appropriate by the health professional in my child's building.

    Parent/Guardian signature:▁▁▁▁▁▁  Date:▁▁▁▁▁▁

    137/07