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Greene CSD Student Health History (Public Link for Open House)

Greene CSD is requesting that you fill out the Student Health History form for the nurses to better know your child. This form is confidential and only intended for the School Nurse.

Child's Name: *

Child's Date of Birth *

Child's Age: (Number) *

Child's Gender (At Birth): *

Male

Female

What is the Child's Grade: *

CPSE- Special Education

UPK

K

1

2

3

4

5

6

7

8

9

10

11

12

Parent/Guardian Name: *

Parent/Guardian Phone: (Number) *

Parent/Guardian Alternate Phone: (Number) *

Has you child ever had an ongoing medical condition? *

Yes

No

If yes, please explain and include date:

Has your child ever seen a medical specialist? *

Yes

No

If yes, please explain and include date:

Does your child have any allergies? *

Yes

No

If yes, please explain:

Has your child ever been hospitalized? *

Yes

No

If yes, please explain and include date:

Has your child ever had an operation? *

Yes

No

If yes, please explain and include date:

Has your child ever had an injury requiring an Emergency Room visit? *

Yes

No

If yes, please explain and include date:

Has your child ever missed 5 days of school in a row due to illness/injury? *

Yes

No

If yes, please explain and include date:

Has your child ever passed out, had a concussion, or serious head injury? *

Yes

No

If yes, please explain and include date:

Has your child ever had a convulsion/seizure? *

Yes

No

If yes, please explain and include date:

Has your child ever had vision problems or conditions? *

Yes

No

If yes, please explain and include date:

Has your child ever had a hearing problem or condition? *

Yes

No

If yes, please explain and include date:

Has your child worn dental bridges, braces, or mouthpieces? *

Yes

No

If yes, please explain and include date:

Has any of your family members under the age of 50 ever had a heart attack? *

Yes

No

If yes, please explain and provide relationship to child.

Have any of your family members under the age of 50 ever had other serious health problems? *

Yes

No

If yes, please explain and provide relationship to child.

Check all that apply to your child: *

ADHD
Asthma/Trouble Breathing
Autism/Asperger
Dental Injuries
Diabetes
Ear Infections
GI Conditions (Ulcer, Reflux, IBS)
Headache/Migraines
Heart Conditions
High Blood Pressure
Mental Health Condition (Depression, Eating Disorder, Anxiety, OCD, ODD, etc.)
Scoliosis
Single Organ (Kidney)
Single Organ (Testicle)
Skin Condition
Speech Condition
Urinary Condition
None

Current Medications- Given at School *

Yes

No

Please list medication name, dose, time(s):

Current Medications- Taken at Home *

Yes

No

Please list medication name, dose, time(s):

Assistive Equipment- *

Used During School

Used Outside of School

None

Please state what assistive equipment child uses:

Treatments *

Given During School

Given Outside of School

None

Please provide the type of treatment (IE Insulin/Blood Glucose Monitoring, breathing treatments/inhaler/peak flow monitoring, and/or special diet:

Is there any condition that would prevent your child from participating in physical education or sports? *

Yes

No

If yes, please explain those concerns:

In Case of Emergency please list Hospital of Choice: *

By signing below, I certify that all information provided is accurate and that I have not knowingly or intentionally provided false information in an attempt to mislead or deceive Greene Central School District or its employees responsible for the collection of such information.

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