CHILD’S HEALTH FORM

Demographic Profile

Child’s Name: Sex:

Date of Birth: Place of Birth:

Address:

Street Barangay Province/City

Child’s Handedness (check appropriate box):

Right Left

Both Not yet established

Is the child studying (check the appropriate box):

Yes No

If yes, what is the name of the child’s learning center:

Child’s Religion: Ethnicity:

Family Background

Father’s Name: Mother’s Name:

Age: Age:

Educational Attainment: Educational Attainment:

Occupation: Occupation:

Phone: Phone:

Email: Email:

Child’s Number of Siblings:

Child's Birth Order (1st, 2nd, 3rd, etc.):

Health History

Please check answers to questions in the column on the right ( Please explain "yes"
answers in the space below):

Is your child currently: Yes No Give details

 • Receiving treatment from the doctor?
• Taking medication/s?

Has your child suffered from:

• Allergies to medicine?
• Any serious illness?
• Any congenital heart condition?
• Any other allergies?
• Allergies to food or bee stings?
• Uses contacts or glasses?
• Any problem on hearing?
• Any problem with speech?
• Any broken bones or dislocation?
• Any muscle or joint injuries?
• Problems running?
• Has only one kidney?
• Excessive weight/gain loss?
• Dental braces/ caps or bridges?
• Problems breathing/ coughing?
• Asthma treatment (past 3 years)?
• Seizure treatment (past 2 years)?
• Diabetes?
Is there anything you want to discuss with the school nurse?
Yes No

If yes, please explain :

Immunization Check
Check the box if the child had already vaccinated against the following disease/s:
Diphtheria tetanus

Whooping cough polio

Measles mumps

Rubella haemophilus influenza

Chickenpox other (please specify)

Learning Needs

Check all areas in which your child has received education services:

reading writing math

behavior social skills study skills
speech language occupational therapy
therapy
Estimate the amount of time your child needs special education services in the areas
checked above:
½ day or less (0-4)
More than ½ (more than 4 hours)
Special help for speech/language
Occupational therapy
Physical therapy

Does your child have any physical, emotional, or medical problem?

Yes No

If yes, please describe:

Please list any other concerns you have about your child’s learning needs:

Physical Assessment

Height: Weight: BMI: BP:

Waist Circumference: Hip Circumference: Mid Upper Arm Head
Circumference: Circumference:

Physical Assessment Normal Abnormal (please explain

further)
Eyes

Ears

Neck

Skin

Hair

Nose
Mouth

Arms

Hands

Waists

Face

Trunk

Feet

Extremities

Behavior and temperament

General appearance:

Fat

Thin

I give permission for release and exchange of information on this form between the school
nurse and health care provider for confidential use in meeting my child’s health educational
needs in school.

Signature of parent/guardian over printed name