ANNUAL HEALTH QUESTIONNAIRE

Child's Name: __________________________________________ Date of Birth: __________
Teacher : ________________________________________ Grade : _____________________
Physician : _______________________________  Dentist : ___________________________ 

1.  Has your child had a routine physical examination in the last year?                   ____yes ____no
     If yes, date :  ___________________________________________

 2.  Has your child had any immunizations in the past year?                                   ____yes ____no
     If yes, what :__________________________ Date : ____________
      Please attach an updated copy of your child’s immunization sheet.

 3.  Is there anything about your child’s health you wish to discuss with me?           ____yes ____no
_________________________________________________________                   

 4.  Has your child been to a dentist in the last year?  Date: ________                   ____yes ____no

 5.  Has your child been to any other physician in the past year?                            ____yes ____no
     (i.e. eye doctor, ENT, allergist, psychiatrist, any other)
     If yes, Name of doctor: _____________________________________
     Reason/Outcome/Treatment:_________________________________

6.  Has your child had any recent illnesses or injuries?                                           ____yes ____no
    If yes, describe: ___________________________________________

7.  Does your child have any allergies? ( i.e. food, bee sting)                                 ____yes ____no
     If yes, describe: ___________________________________________
     Treatment/Medication:_________________________________

8.  Does your child take any medication on a regular basis?                                    ____yes ____no
     If yes, name of medication and dosage: _________________________
     Reason: __________________________________________________

      * PLEASE NOTE ALL PRESCRIPTION MEDICATIONS NEED WRITTEN PHYSICIAN AND PARENTAL ORDERS.  MEDICINE MUST BE BROUGHT TO SCHOOL BY AN ADULT IN THE ORIGINAL CONTAINER.

9.   Does your child have health insurance coverage?                                              ____Yes ____no
      If no, would you like information regarding health insurance options?                ____Yes ____no  

Parent’s Signature: ____________________________________ Date ____________                                                 

OPTIONAL: Does anyone have a court ordered forbidden access to your child?     ____Yes ____no
If yes, Name:_____________________________________ (copy of court document required)