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ABOUT OUR SCHOOL
Mission
Curriculum
Faculty & Staff
Our History
FAQ’s
FOR PARENTS
Policies & Plans
Parent & Community Groups
Student Forms
Out-Of-District Enrollment
Census
CALENDAR
PHOTOS & PRESS
MEETINGS & MINUTES
School Board Meetings
Shared Decision Making
Committee Agendas
Additional Documents
DISTRICT & BOARD
Board of Trustees
District Budget
School Statistics
NYS School Report Cards
CONTACT US
Health Registration Form
Home
Health Registration Form
Health Registration Form
Health Registration Form
Student's information
Name
*
Name
First
First
Middle
Middle
Last
Last
Date of Birth
*
Gender
*
Male
Female
N/A
Phone Number
*
Email Address
*
Emergency Contact
Emergency Contact Name
*
Emergency Contact Name
First
First
Last
Last
Relationship to Student
*
Mother
Father
Guardian
Sister/Brother
Partner
Emergency Contact Number
*
Social Development
Language child usually speaks at home
Is you child
Left Handed
Right Handed
Does your child do simple household tasks?
yes
no
Does you child prefer to socialize with
peers
alone
Do you consider your child overly shy?
yes
no
Do you consider your child over-active
yes
no
Has your child ever have a sleeping problem?
yes
no
Has your child ever had an eating disorder?
yes
no
Physical Development
Do you think your child is average in height
yes
no
Do you think your child is average in weight
yes
no
Does you child fall frequently
yes
no
Does you child bump into objects around him/her
yes
no
Rate your child on the following skills compared with other children the same age (circle one):
Walking
good
average
poor
Running
good
average
poor
Throwing
good
average
poor
Catching
good
average
poor
Athletic Ability
good
average
poor
Writing
good
average
poor
Family History
Select any of the following diseases that your child’s parents, grandparents, aunts, uncles, brothers, sisters have had. (Check M to indicate maternal or P to indicate paternal.)
Tuberculosis
M
P
Diabetes
M
P
Mental Illness
M
P
Asthma
M
P
Epilepsy
M
P
Cancer
M
P
Allergic Reactions
M
P
Allergic to what substance?
Inherited Diseases
M
P
Other?
Are the child’s parents both in good health?
yes
no
What is the general health of brothers and sisters?
Birth History
Was the child adopted?
yes
noi
Normal pregnancy
yes
no
If pregnancy wasn’t normal, please explain (spotting, toxemia, premature, illnesses, accidents, etc.):
If premature, how many weeks?
Any marks on baby?
yes
no
Do any foods disagree with him/her
yes
no
If yes, please explain
Does he/she often have diarrhea?
yes
no
Has constipation ever been much of a problem?
yes
no
Are immunizations complete?
yes
no
Was your child born with any congenital diseases or abnormalities
yes
no
If yes, please explain (Sickle Cell Anemia, kidney disease, PKU, congenital hip, club foot?)
Current Health Status
Allergies
Yes
Onset
Asthma
Yes
Onset
Broken Bones
Left
Right
Specify
Chest pain
yes
High blood pressure
yes
Chicken pox
Yes
When?
Convulsive disorder/seizure (due to high fever, etc.),
Yes
Onset
Diabetes
Yes
Onset
Any pain or lumps in your groin?
yes
no
Discharge from penis?
yes
no
Epilepsy
yes
no
Onset
Frequent colds and/or sore throats
yes
no
Frequent headaches
yes
no
Has menstruation begun?
yes
no
Month/Year
Are periods painful?
yes
no
Regularly?
yes
no
Hearing difficulties and/or infections
yes
no
Operations? (specify)
Pains in extremities or joints
yes
no
Physical handicap (specify)
Pneumonia
yes
no
Rheumatic fever
yes
no
Onset
Scarlet fever
yes
no
Onset
Scoliosis
yes
no
Onset
Serious injury, specify
Serious burns, specify
Skin conditions, specify
Special or poor eating habits
yes
no
Special or poor eating habits
yes
no
Speech difficulties
yes
no
Tuberculosis
yes
no
Onset
Urinary conditions (specify)
pain
burning
blood
Vision – wears glasses?
yes
no
Other (specify)
Currently under a physician’s care?
yes
no
Name of Physician
Currently under a dentist’s care?
yes
no
Name of Dentist
Medication (Please indicate name and dosage of any medication your child is taking)
Ever been hospitalized?
yes
no
Condition?
If yes, when?
Is there anything else you would like to tell us about your child to help him/her to have a positive school experience?
Emotional
Is he/she doing well in school?
yes
no
Radio Does he/she get along well with peers?
yes
no
Circle any of the following which your child has:
Nail biting
Breath holding
Jealousy
Irritable
Nightmares
Thumbsucking
Bad temper
Bedwetting
Other
Other
5. How much time does your child spend watching TV each day?
Favorite TV program?
Does he/she play alone?
yes
no
Does he/she play quiet games?
yes
no
Active games?
yes
no
Does he/she interact with peers?
yes
no
Does your child participate in organized activities or take part in other classes?
yes
no
(Please explain)
Has your child ever experienced family moving
yes
no
How many times
Has your child ever lived with someone other than his/her parents?
yes
no
When
With whom?
. Has your child had a traumatic experience lately?
yes
no
If so, please explain:
Has your child ever experienced a death in the family?
yes
no
Whom?
When
Has your child ever experienced a parent or other family member with a long illness?
yes
no
Has your child had periods of sadness or depression?
yes
no
Relationship to child
Date
Signature
signature
keyboard
Clear
If you are human, leave this field blank.
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