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