Health Questionnaire

Please complete the form below. Required fields marked with an asterisk *

Student's name:

Answer required for "Student's name:"

Date of Birth

Answer required for "Date of Birth"

Child's doctor and phone number:

Answer required for "Child's doctor and phone number:"

Prenatal

When you were pregnant, were you sick during your pregnancy?

Answer required for "When you were pregnant, were you sick during your pregnancy?"

Yes

When you were pregnant, did you have to use any medicine?

Answer required for "When you were pregnant, did you have to use any medicine?"

Yes

How long was your pregnancy?

Answer required for "How long was your pregnancy?"

What type of delivery did you have?

Answer required for "What type of delivery did you have?"

Neonatal

How much did your baby weigh at birth?

Answer required for "How much did your baby weigh at birth?"

Was your baby sick in the first few days of life? (if yes, explain)

Answer required for "Was your baby sick in the first few days of life? (if yes, explain)"

Health issues

Has your child ever had asthma?

Answer required for "Has your child ever had asthma?"

Yes

If your child has had asthma please answer the following questions.

At what age did your child have their first asthma attack?

Answer required for "At what age did your child have their first asthma attack?"

How often does your child have asthma attacks?

Answer required for "How often does your child have asthma attacks?"

When did your child have their last asthma attack?

Answer required for "When did your child have their last asthma attack?"

Has your child been hospitalized for asthma? How often?

Answer required for "Has your child been hospitalized for asthma? How often?"

When was your child’s last hospitalization for asthma?

Answer required for "When was your child’s last hospitalization for asthma?"

Has your child used asthma medicine in the past two years?

Answer required for "Has your child used asthma medicine in the past two years?"

If your child needs asthma medicine, the school nurse will require a written medicine order from your doctor, for your child, so that we can care for your child if your child has an asthma attack while they attend school.

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Has your child ever been in the hospital for any reason?

Answer required for "Has your child ever been in the hospital for any reason?"

Yes

If yes, When? Why? For how many days?

Answer required for "If yes, When? Why? For how many days?"

Has your child ever had any broken bones?

Answer required for "Has your child ever had any broken bones?"

Yes

If yes, when? Explain.

Answer required for "If yes, when? Explain."

Does your child have any allergies?

Answer required for "Does your child have any allergies?"

Yes

If yes, please explain.

Answer required for "If yes, please explain."

Does your child have any other health problems?

Answer required for "Does your child have any other health problems?"

Yes

If yes, please explain.

Answer required for "If yes, please explain."

At what age did your child first walk?

Answer required for "At what age did your child first walk?"

At what age did your child talk in sentences?

Answer required for "At what age did your child talk in sentences?"

At what age was fully toilet trained?

Answer required for "At what age was fully toilet trained?"

If your child has siblings, please write their names and the year they were born.

Answer required for "If your child has siblings, please write their names and the year they were born."

Parent/Guardian's signature:

Answer required for "Parent/Guardian's signature:"

Date:

Answer required for "Date:"

Please fix the highlighted areas below before submitting.

Health Questionnaire