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    Main - Initial Student Health History New Mexico

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    princess justine Dumayaca

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    Main - Initial Student Health History New Mexico

    Uploaded by

    princess justine Dumayaca
    1 views3 pages

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    main_initial-student-health-history-new-mexico

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    1 views3 pages

    Main - Initial Student Health History New Mexico

    Uploaded by

    princess justine Dumayaca

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 3

    INITIAL STUDENT HEALTH HISTORY

    (Parent/Guardian: The purpose of this form is to identify problems that may affect learning for the student. You may choose not to
    answer any question. The school nurse is available to help you at # M T W Th F)

    Student Name: DOB: Student #:


    Person Providing History: Relationship to Student:
    Is this person the biological parent? Y N
    Home Phone: Work Phone: Cell Phone:

    BIRTH
    1. BirthHISTORY
    Weight: Birth Length: Age in weeks at birth: Full Post Term
    Premature Term
    2. Difficult pregnancy (e.g. pre-term contractions, bleeding, illness/infection, eclampsia, pregnancy
    related diabetes):
    Y N If Y, explain:
    3. Medications/drugs taken during the pregnancy: None Over the Counter Prescription
    Alcohol Street Drugs Explain reason for medications:

    4.Did student have problems after birth (e.g. difficulty breathing, yellow skin)? Y N
    5. Did student receive special care after birth? Y N Explain:

    6. Length of birth hospital stay: Explain:

    DEVELOPMENTAL
    1.Has HISTORYphysical, occupational, speech, or language therapy?
    the student received Y N
    If Y, explain:
    2.Are you or has anyone ever been concerned about the student’s development? Y N
    If Y, explain:

    HEALTH HISTORY
    Check any of the following which the student currently has or has had diagnosed
    in the past. Asthma Cancer Convulsion or
    seizures
    Allergies Depression Excessive thirst
    Anaphylaxis Diabetes Head injury
    Anemia Kidney disease Heart problems or murmur
    ADD/ADHD Frequent Urination Hepatitis (yellow jaundice)
    Thyroid disease Nerve or muscle disease Ingestion of
    poisons/medication Shingles Frequent/severe headaches
    Vaccine Preventable Diseases Life changing events/accidents
    Other health concerns
    Explain any check mark and give age of problem onset or diagnosis:

    1. List any other diagnosis, syndrome or disability the student has or has had in past. (List
    condition, treatment, who diagnosed, etc.)

    2. Has the student had more than 3 colds, sinus infections, or ear infections in any one year? Y N
    If Y, explain:
    3. Has the student ever had any vision or hearing problems? Y N
    If Y, explain:
    Adapted from Albuquerque Public Schools page 1 of 2
    4. Medication - Is the student taking medication now? Y N
    If Y, list the medications (include prescribed, over-the-counter, herbal and other remedies) and
    the condition for which the student takes this remedy):

    Has the student ever taken any medication for longer than two weeks? Y N
    If Y, list medication and when it was taken?

    5. Sleep – Number of hours of sleep the student gets most nights: Normal bedtime:

    Student falls asleep easily. Y N Student wakes up easily. Y N


    Student wakes up rested. Y Student’s sleep soun restless.
    N is: d

    Studen snore wets his/her pants or wets has other sleep issues.
    t: s the bed
    Explain:

    Student has a usual bedtime routine. Y N Student


    sleeps in his/her own bed. Y N .

    6. Nutrition – Student eats at least 3 meals each day.


    Y is sometimes picky is sometimes not picky.
    N
    Student: has healthy appetite is picky eater
    Do you have any concerns about student’s eating? Y N
    If Y, explain:
    Do you have any concerns about student’s physical activity? Y N
    If Y, explain:
    Does student have any food allergies? Y N
    If Y, explain:

    7. Behavior – Student has friendships that seem normal for his/her age. Y N
    If N, explain:
    Do you have any concerns about student’s behavior? Y
    N
    If Y, explain:

    8. What schools has student previously attended?


    9. How many days of school has student missed in the last year? or been tardy?

    Primary
    MEDICAL CARECare Provider: Phone #:
    Other providers/physicians/specialists:
    Medical Insurance: Medicaid/Salud MCO:
    Medicaid #:
    Other Insurance/Coverage:
    No Other Insurance/Coverage
    Date of last physical exam: Date copy of provider report requested:
    Summary of Findings:
    Date of last dental visit/exam: Summary of Findings:

    Adapted from Albuquerque Public Schools page 2 of 2


    School Nurse Name:

    Nurse Signature: Date:

    Adapted from Albuquerque Public Schools page 3 of 2

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