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Health History Form

STUDENT INFORMATION
Doctor
Date of last exam:
Dentist
Date of last exam:
HEALTH QUESTIONNAIRE

If the answer to the question is “YES,” please explain 

First Name

Last Name

Middle Name

PROVIDER INFORMATION

Date of Birth

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Standard Authorization for Exchange of Health Information

STUDENT INFORMATION

Last Name

First name

Middle Name

Date of Birth

Street Address

AUTHORIZATION

This form authorizes the exchange of Protected Health Information (PHI) and education records (including personally identifiable information obtained therefrom) between your Child's health care provider and authorized school officials. 

Description of the documents and information to be disclosed:

Documentation mandated by the New York State Education Department.
          -  Pre-participation history and physical examinations for athletics
          -  Mandated health history and physical examinations
          -  Return-to-school post-injury or illness and medical documentation of permissible activity
          -  Immunizations
          -  Medications administered to or by a child at school
          -  Academic performance information, if relevant to medical condition(s)
          -  Therapy services (OT, PT, ST) being provided to the student
Documentation related to accommodations requested/required for asthma, concussions, or other medical conditions

This release does not apply to mental health, alcohol/drug, HIV or other information which, by law, cannot be released without specific authorization.  

(Name and address of student's physician or other provider)

Information is to be disclosed between the Ithaca City School District (ICSD), and school physician(s) and nursing staff at the school the child attends and  

It is necessary for ICSD to share health information with the student’s health care providers to facilitate and promote informed recommendations and decision-making by both the health care provider and school district with respect to the student’s educational program.  This release authorizes disclosure of the records described above and personally-identifiable information obtained therefrom by ICSD to the student’s health care providers for the following purposes: 

●    To comply with a  request from the student’s parent/person in parental relation and/or legal guardian, or the student (if age 18 or older and competent);
●    To assist with an evaluation or the provisions of services by ICSD;
●    To coordinate the provision of medical services;
●    Other (please specify); 

This authorization shall remain valid until either (​choose one​):

ACKNOWLEDGEMENT

I hereby, knowingly, and voluntarily authorize the above-named agency/provider to use or disclose this 
information only in the manner described above.  I understand treatment, payment, and health plan enrollment will not be conditioned on my authorization of this disclosure.  I understand that I may revoke this authorization in writing at any time. 

Current Signature

9/18/16

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This is confidential information that will be maintained by the school nurses

Street Address

City

State

Zip

City

State

Zip

Before submitting form, please verify your answers on all pages. Moving back to other pages will not erase your work. After pressing SUBMIT FORM, if there are errors, they will be noted in red.

Grade Entering

Grade Entering

Does your child have an ongoing or chronic illness?

Has your child ever been hospitalized?

Has your child ever had surgery? What and When?

Does your child take any prescription or non-prescription medications? Please list all, including vitamins & fluoride.

Does your child have any allergies ​(for example: food, insects, medication, latex, environmental)​ ?

If your child has allergies, is it life threatening? Are they prescribed emergency medication ​(for example, EpiPen, Benadryl, inhaler, or other?)

Has your child ever fainted or been dizzy during exercise which required medical care?

Has your child ever had chest pain during or after exercise which required medical care?

Have you been told your child has a heart murmur or heart problems?

Does your child get frequent or severe nosebleeds?

Does your child regularly take any medications for constipation or diarrhea?

Does your child have any significant skin concerns (for example: itching, rash, eczema, acne, warts)?

Has your child ever been diagnosed with a concussion?

Has your child ever had a nonfebrile (without fever) seizure requiring medical follow-up?

Does your child have asthma or reactive airway disease?

Does your child take asthma medication, use an inhaler or nebulizer?

Does your child use any special protective or corrective equipment ​(for example: back brace, orthotics, hearing aid or ear tubes, glasses)?

Does your child have dental cavities or concerns which are not being treated by a dentist?

Has your child had any broken bones or problems with pain or swelling in muscles, bones or joints?

Do you feel your child is underweight or overweight?

Do you feel your child experiences stress, anxiety or get emotionally upset easily?

(For girls ONLY - If boy select N/A) Has your daughter had her menstrual period?

If yes, when was her first menstrual period? 

Please note any concerns that you have with her menstrual period in the box above. 

Is there a family history of sudden cardiac death?

Do you have any other concerns about your child's health?

Do you have any concerns about your child attending school?

Do you need help with securing health insurance for your child?

Relationship to student