Health Registration Form

Health Registration Form

Health Registration Form

Student's information

Name
Name
First
Middle
Last

Emergency Contact

Emergency Contact Name
Emergency Contact Name
First
Last

Social Development

Is you child
Does your child do simple household tasks?
Does you child prefer to socialize with
Do you consider your child overly shy?
Do you consider your child over-active
Has your child ever have a sleeping problem?
Has your child ever had an eating disorder?

Physical Development

Do you think your child is average in height
Do you think your child is average in weight
Does you child fall frequently
Does you child bump into objects around him/her

Rate your child on the following skills compared with other children the same age (circle one):

Walking
Running
Throwing
Catching
Athletic Ability
Writing

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
Diabetes
Mental Illness
Asthma
Epilepsy
Cancer
Allergic Reactions
Inherited Diseases
Are the child’s parents both in good health?

Birth History

Was the child adopted?
Normal pregnancy
Any marks on baby?
Do any foods disagree with him/her
Does he/she often have diarrhea?
Has constipation ever been much of a problem?
Are immunizations complete?
Was your child born with any congenital diseases or abnormalities

Current Health Status

Allergies
Asthma
Broken Bones
Chest pain
High blood pressure
Chicken pox
Convulsive disorder/seizure (due to high fever, etc.),
Diabetes
Any pain or lumps in your groin?
Discharge from penis?
Epilepsy
Frequent colds and/or sore throats
Frequent headaches
Has menstruation begun?
Are periods painful?
Regularly?
Hearing difficulties and/or infections
Pains in extremities or joints
Pneumonia
Rheumatic fever
Scarlet fever
Scoliosis
Special or poor eating habits
Special or poor eating habits
Speech difficulties
Tuberculosis
Urinary conditions (specify)
Vision – wears glasses?
Currently under a physician’s care?
Currently under a dentist’s care?
Ever been hospitalized?

Emotional

Is he/she doing well in school?
Radio Does he/she get along well with peers?
Circle any of the following which your child has:
Does he/she play alone?
Does he/she play quiet games?
Active games?
Does he/she interact with peers?
Does your child participate in organized activities or take part in other classes?
Has your child ever experienced family moving
Has your child ever lived with someone other than his/her parents?
. Has your child had a traumatic experience lately?
Has your child ever experienced a death in the family?
Has your child ever experienced a parent or other family member with a long illness?
Has your child had periods of sadness or depression?
Start Over

february, 2023

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