INTERVAL HEALTH HISTORY

Child’s Name______________________________________ Date______________________

Do you consider your child’s health to be GOOD_________ FAIR_________ POOR_________ Can your child participate in full school activities?_____________________ Grade___________

Does your child have any allergies to:

Foods____ Animals____ Medicine_____ Dust_____ Pollen______ Insects______ Other______

Please specify:__________________________________________________________________

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Has your child had any problems with: (check all that apply and describe)

____Asthma _____Heart Disease

____Eczema _____Persistent coughing or wheezing

____Frequent headaches _____Tires easily

____Dizziness _____Stomach aches/vomiting

____Fainting Spells _____Diarrhea/constipation

____Seizures _____Hernia

____Tonsils/adenoids _____Kidney disease/urinary frequency

____Strep throat _____Painful joints

____Frequent nosebleeds _____Depression

____Anxiety _____Mood disorder

____Scoliosis _____ADHD

____Concussion (Please note number of times)

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If so, is this condition under the care or observation of a doctor? _____Yes _____No

Doctor’s name and address:_______________________________________________________

Has your child had any: (please specify)

____Serious injuries _____Operations

____Accidents _____Serious illness (other than above)

_____________________________________________________________________________

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Does your child have any eye problems? (Difficulty seeing, crossed eyes, frequently red or watery)_______________________________________________________________________

Does your child wear glasses or contacts?____________________________________________

Does your child have any ear or hearing problems? (Hearing loss, frequent earaches or ringing)

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Please list any special information you would like your child’s teacher to know about:

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