HEALTH HISTORY QUESTIONNAIRE Westbrook School Department 2016 - 2017 Dear Parents: This questionnaire is designed to help us to get to know your child as you have seen him or her develop in the early years at home. This information, along with other observations, will help us plan the best start in school for your child. Child’s Name:_________________________________________Date of Birth:__________________ Parent/Guardian’s Name:_______________________________Tel. Number:__________________ Address:_____________________________________________________________________________ Child’s Physician:______________________________________Tel. Number:___________________ Family Dentist:________________________________________Tel. Number:___________________

PLEASE BRING YOUR CHILD’S IMMUNIZATION RECORD WHEN YOU REGISTER YOUR CHILD.

Be sure to call your child’s doctor if you do not have it at home. Health records are mandatory by the state. If we do not have it by the beginning of school, your child may be required to not enter school until it has been seen.

Past Health Status Chronic conditions: (allergies, asthma, migraines, diabetes, epilepsy, cancer, heart disease, cystic fibrosis) ______________________________________________________________ ______________________________________________________________ __________________ Childhood Illnesses: ______________________________________________ Hospitalizations: _________________________________________________ Development (bowel & bladder control) _____________________________ Behavior Problems (overactive, excessive shyness, aggressiveness) ________________________________________________________________________ ________________________________________________________________________

Are you concerned about your child’s hearing or vision? Explain: ________________________________________________________________________ ________________________________________________________________________ Over Has your child had frequent ear infections? ________________________________________________________________________ Medications: (name, dose, time taken):______________________________ ________________________________________________________________________

Family History – Any medical difficulties? (Migraines, diabetes, early heart disease, hypertension, blood diseases, seizure disorders, emotional stresses, cancer, alcoholism, kidney disease, retardation, allergies, lung diseases, musculoskeletal disease) ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Obstetrical History – Any problem experienced during pregnancy with this child? (viral infection,toxemia, trauma, vaginal bleeding, chronic disease, premature birth, breech birth, multiple births Other Comments ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________

Please bring this form to registration. Any questions regarding the form should be addressed to the nurse. CANAL SCHOOL Telephone: 207-854-0840 Fax: 207-854-0855 Ann Brown, LPN

CONGIN SCHOOL Telephone: 207-854-0844 Fax: 207-854-0846 Attention: Margaret Landry, LPN

SACCAEAPPA SHOOL Telephone: 207-854-0847 Fax: 207-854-0849 Cindy Horr, LPN

Date Reviewed:_______________________________________ Signature of Parent:_____________________________________ Signature of Nurse:_____________________________________

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