Portal

LaFayette Central School District

5955 US Route 20 West LaFayette, NY 13084
315-677-9728 (p)/315-677-3372 (f)
www.lafayetteschools.org

Health History Form

STUDENT INFORMATION

Last Name*

First Name*

Middle Name

Date of Birth*

HEALTH HISTORY

Yes No

Does your child have any allergies to food?

Which ones and what is the reaction?

Yes No

Does your child have any medication allergies?

Which ones and what was the reaction?

Yes No

Does your child have any environmental allergies?

Which ones and what was the reaction?

Yes No

Is your child allergic to bee stings?

Yes No

Does he/she require immediate medication?

What is the medication(s)?

Yes No

Does your child have Asthma?

What are the things that aggravate it?

Yes No

Does he/she require medication to control it?

What medication(s)? (Name, dose, frequency)

If she/he will require these medications in school, please complete the Medication Authorization Form available on the website.

Yes No

Does your child have diabetes?

Please explain the treatment he/she is receiving.

If fingersticks and/or medication are required in school, please complete the Medication Authorization From available on the website.

Yes No

Does your child have a cardiac condition?

This includes, but not limited to, a murmur, chest pain, arrhythmia, elevated blood pressure, history of rheumatic fever or any history of cardiac surgery.

If your child is on any physical activity restrictions due to a cardiac condition please contact the nurse's office.

Yes No

Does your child have a history of any head injury, seizures, headaches, migraines, concussion or other neurological conditions?

Yes No

Does your child have any ear problems or hearing loss?

Yes No

Does your child have any eye problems or vision loss?

Yes No

Does your child wear glasses/contact lenses?

Yes No

Does your child have any kidney/bladder problems and or only one kidney?

Does your child have any musculosketal problems including, but not limited to, arthritis, fractured/dislocated bones, any muscle strain, ligament tear, joint sparain, back pain, neck injury, or anything else you feel we should be aware of?

Yes No

Please explain, and please include dates if any injuries.

Please explain.

Yes No

Does your child have any history of anemia, injury to spleen or frequent nose bleeds?

Please explain.

Does your child have any history of gastrointestinal problems including but not limited to, stomach ulcers, Crohn's disease, irratable bowel syndrome, reflux, hiatal hernia or any condition you feel we should be aware of?

Yes No

Please explain.

Yes No

Has your child ever had x-rays or required operations?

Please explain and include dates.

Yes No

Is your child under medical care now?

Please explain.

Yes No

Has your child taken any medication in the past year?

Please include name of medication, dose and reason for taking it.

Yes No

Does your child have orthodontic appliances?

Please explain.

Yes No

Is there anything else you feel we should be aware of regarding your child's health and or well being?

Please explain.

Grade

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