Health History Form

Information on health histories and health exams are kept confidential.
Name
DOB
Phone  
Address 
City  State Zip


Name & phone number of parent or guardian

Business phone number of parent or guardian

Name & phone number of person to notify in case of emergency (other than parent or guardian)

Relationship

Name & phone number of girl’s physician

Family medical hospital insurance carrier

Policy/Group #

Part I: Illnesses and Injuries (Check those that apply)
Asthma Diabetes Epilepsy Kidney Disease
Convulsions Ear Infection Heart Disease Other

Date of your daughter’s last health examination

Were any medical problems noted in your daughter’s last health examination?

Is your daughter currently under a physician’s care for a medical problem?

Since her last health exam, has your daughter had:

a serious injury requiring medical attention?

an illness lasting longer than one week?

a surgical operation or fracture?

medication prescribed by a physician to be taken on a regular basis?

treatment in a hospital as an inpatient or in the emergency room?

Is your daughter restricted from participating in any school physical education activity?

Please explain any “yes” answers to the above questions. Include dates.
A written statement from your daughter’s physician granting her permission to participate in strenuous activity such as water sports, horseback riding, skiing, hiking, non-contact sports such as track, tennis, or gymnastics is required if: she has a known complicating medical problem or has had a serious illness or injury or an operation since her last health exam or is taking medication prescribed by a physician on a regular basis.

Part II: Allergies (Check those that apply)
Animals (specify)

Food (specify)

Hay Fever (specify)

Insect stings (specify)

Medicines/drugs (specify)

Plants (specify)

Pollen (specify)

Other (specify)

Part III: Immunizations MUST HAVE DATES – DO NOT WRITE “UP TO DATE”
Immunization Primary Last Booster
D.T.P.
Oral Polio
Rubella
Measles
Mumps
Other
     
Tuberculin Test Type
  Last year given

Part IV: Other Health Conditions (Check those that apply)

Bed wetting Constipation Emotional disturbances
Fainting Hearing impairment Menstrual cramps
Motion sickness Nose bleeds Sickle cell anemia
Sleep walks Special dietary Wears contact lenses
Wears glasses Other (specify)

Please explain any “yes” answers to the above questions. Indicate any information useful to the adult in charge in relation to any of these health conditions. Also, indicate any activities to be encouraged or restricted.



This health history is correct and complete as far as I know, and the person herein described has permission to engage in all activities except as noted.

______________________ Signature