HEALTH APPRAISAL (Page 1 - To be filled out by parent or guardian)

HEALTH APPRAISAL

(Page 1 - To be filled out by parent or guardian)
Dear Parent or Guardian: The following information is requested so that the school can work with the parent to meet the physical, intellectual and emotional needs of the child. Fill out the information requested in Section I. Section III may be certified by the transcription of information from the certificate of immunization. The remaining sections are to be completed by a doctor, nurse and dentist. (BE SURE TO BRING YOUR CHILD'S IMMUNIZATION RECORDS TO THE EXAMINATION.)
Today's Date*

MonthDayYear
Date
PERSONAL
Child's Name (Last, First, Middle)*
Date of Birth (mm/dd/yy)*

MonthDayYear
Date
Address*

Number & Street

Street Address Line 2

City

ZIP Code
Parent/Guardian (Last, First)*
Home Telephone Number*
Work Telephone Number
SECTION I - HEALTH HISTORY

Is your child having any of the problems listed below?*

	Yes	No	Resolved
Allergies or Reactions (for example, food, medication or other)
Hay Fever, Asthma, or Wheezing
Eczema or Frequent Skin Rashes
Convulsions/Seizures
Heart Trouble
Diabetes
Frequent Colds, Sore Throats, Earaches (4 or more per year)
Trouble with Passing Urine or Bowel Movements
Shortness of Breath
Speech Problems
Menstrual Problems
Dental Problems
Other (please describe below):

HEALTH APPRAISAL