HEALTH QUESTIONNAIRE
Interval or Update Health History

Student Name _________________________________ Date of Birth _________________

Address ______________________________________________________________________

Grade __________________ School ______________________________________________

Date ___________________ To be completed by parent or student.

Circle Answer

1. Have you been in good health in the past year?………………………………Yes      No

If no, please explain______________________________________________________

__________________________________________________________________________

2. Have you had any if the following in the past year:

a) any illness lasting more than three (3) days?…………………………. Yes   No
b) any severe injuries or accidents?……………………………………... Yes   No
c) any sprains or strains?………………………………………………… Yes   No
d) any sprains or strains?………………………………………………... Yes   No
e) any time in hospital?…………………………………………………. Yes   No
f) any operations?………………………………………………………. Yes   No
g) any drugs or treatments prescribed by a physician or clinic?………... Yes   No

If yes to any of the above, please explain._______________________________________

_______________________________________________________________________

_______________________________________________________________________

3. Are you under the care of a physician or clinic now?…………………………No    Yes

Are you taking any drugs or treatments or medications now?……………….No    Yes

If yes to either of the above, please explain _____________________________________

________________________________________________________________________

________________________________________________________________________

4. In the past year have you noticed an of the following problems:

a) trouble with eyes or seeing?.,………………………………………. No Yes
b) have begun to wear glasses?……………………………………….. No Yes
c) have begun to wear contact lenses?………………………………… No Yes
d) trouble with ears or hearing?……………………………………….. No Yes
e) trouble with allergy?………………………………………………... No Yes
f) trouble with asthma or breathing?………………………………….. No Yes
g) trouble with eating or weight gain or loss?…………………………. No Yes
h) trouble with sleeping?………………………………………………. No Yes
i) trouble keeping up with the activities of friends?…………………... No Yes
j) trouble with class work?……………………………………………. No Yes
k) trouble with school?………………………………………………… No Yes
l) trouble with the family?…………………………………………….. No Yes
m) problem with general development and maturity?………………….. No Yes

If yes to any of the above, please explain. _________________________________________

___________________________________________________________________________

___________________________________________________________________________

5. Have you seen a dentist in the past year?…………………………………….No    Yes

Describe the state of your teeth below:

Teeth Missing………………………………………………………………None    Some

Teeth Decayed (cavities)…………………………………………………...None    Some

Teeth Filled…………………………………………………………………None    Some

6. Have you had any immunizations in the past year?…………………………No    Yes

If yes, please explain. ________________________________________________________

__________________________________________________________________________

Have you received the following immunizations?

a) four or more doses of diphtheria and tetanus?…………………….. Yes No
b) three or more doses of polio?……………………………………… Yes No
c) two doses of measles, mumps, rubella?…………………………… Yes No
d) three doses of hepatitis B?…………………………………………. Yes No
e) one or more doses of varivax or had the chicken pox disease?…… Yes No

About how old were you when you had the chicken pox disease?……..____________

7. Has any member of the family developed any serious health problems

in the past year?………………………………………………………………..No    Yes

If yes, please explain. ________________________________________________________

__________________________________________________________________________

8. Do you think you are fit to participate in all school sports, athletics and

Physical Education Class?……………………………………………………...Yes    No

If no, please explain. _________________________________________________________

__________________________________________________________________________

9. Do you have any concerns which you would like to discuss with a nurse

or physician?…………………………………………………………………….No    Yes

If yes, the School Nurse Practitioner will contact you to set up an appointment.