AUSTINTOWN LOCAL SCHOOL DISTRICT
HEALTH HISTORY UPDATE
School Year 2007 - 2008
       
Student Name: ______________________________ Student School: ______________________________
Male   Female D.O.B. ___ / ___ / ___
       

Does your child have a medical condition that we should know about?  No  Yes   (If yes, please describe):

 
       

Allergic to the following:   (please list medications, animals, foods, plants, insects, etc.)

 

Students reaction is:  (please list rash, vomiting, difficulty breathing, etc.)

 
       

List daily medication(s) and / or treatment(s):

 
       

Will child require medication / treatments during school?  No  Yes  (If yes, please list-consent form required)

 
       
Include "history of" by checking the appropriate line (include dates if known)
 Chickenpox  Anemia  Stomach Disorder  Kidney Disease
 German Measles (rubella)  Bleeding / Clotting Problem  Bowel / Intestinal Disorder  Urinary Disorder
 Measles (rubeola)  Nosebleeds (frequent)  Pancreatitis  Sleep Disorder
 Frequent Strep Infections  Weak Blood Vessel (aneurysm)  Ulcers Mental Illness
 Scarlet Fever (scarlatina)  Heart Attack (acute myocardial infarction)  Nervous System Problem  OB / GYN Disorder
 Mumps  Stroke  Seizure Disorder  Eating Disorder
 Rheumatic Fever Heart Defect / Problem  ADHS Ear Infections Tubes in ears
 Hepatitis  Heart Disease  Head Injury  Asthma
 HIV  Heart Failure  Diabetes  Sinusitis
 Cirrhosis  High Blood Pressure (hypertension)  Skin Disorder  Torisillitis
  Muscular or Skeletal Disorder   Physical Limitations or Restrictions

  Vision Problems:

Treatment:

  Hearing Problems:

Treatment:
       

Hospitalizations / Injuries / Surgeries / Other Pertinent Data:

 
       
       

List any immunizations received in the last year  (please include Tetanus Booster):