CHAPTER 8 - BCSD Static Server - Bakersfield City School District

BAKERSFIELD CITY SCHOOL DISTRICT
HEALTH SERVICES – 714 Williams Street
Bakersfield, CA 93305- (661) 631-5895
Date
School
Grade
Teacher
HEALTH HISTORY UPDATE
SID #: Pupil’s Social Security #: - -
Pupil’s Name Sex Birthdate Age
Parents: Father In Home Yes No Mother In Home Yes No
Address
Guardian/Other
Name of Person Completing Form
Phone
Relationship
Relationship
Physician Address Phone #
Current Medication (Indicate name and how often given)
Known Allergies
Is child a Client of: MediCal SSI CCS KRC
Vision Tested: Results Hearing Tested Results
CURRENT HEALTH HISTORY (Review of Systems) Please circle YES to any of the following that your child has had with in the last three (3) years
ILLNESSES (Please give approximate age of illness or injury)
Yes No Age:_ _ Skin infection Yes No Age:_ _ Diabetes with medication
Yes No Age:_ _ Unconscious more than 1 hour Yes No Age:_ _ Anemia
Yes No Age:_ _ Hay fever/Allergies Yes No Age:_ _ Tumor or growth
Yes No Age:_ _ Hospitalization (reason) Date Yes No Age:_ _ Accidental poisoning
Yes No Age:_ _ Asthma Yes No Age:_ _ Other illnesses
Yes No Age:_ _ Frequent fevers
1 - SKIN 7 – GASTROINTESTINAL (continued)
Yes No Rashes / Sores Yes No Poor growth
2 - EYE & VISION Yes No Abdominal pain
Yes No Eye Surgery for Yes No Digestion difficulty
Yes No Vision problems Yes No Bright red blood in stool
Yes No Eye pain or redness Yes No Constipation
Yes No Wears glasses Yes No Diarrhea
Yes No Wears contacts Yes No Soiled pants
3 – EARS & HEARING Yes No Ulcer
Yes No Hearing aids Yes No Other bowel problems
Yes No Hearing problems 8 - GENITAL-URINARY
Yes No Ear infections, drainage (more than 2 per year) Yes No Pain upon urination
Yes No Ear tubes Yes No Frequent urination
4 – NOSE AND THROAT Yes No Frequent daytime accidents
Yes No Bad teeth / Cavities Yes No Bedwetting
Yes No Bloody noses Yes No Blood in urine
Yes No Difficulty swallowing 9 - NEUROLOGICAL
Yes No Swollen glands Yes No Headaches
5 – RESPIRATORY Yes No Cerebral Palsy
Yes No Frequent colds/sore throats Yes No Seizures or convulsions
Yes No Cough Yes No Head injury (unconsciousness)
Yes No Asthma/Current meds Yes No Fatigue (often too tired)
6 - CARDIOVASCULAR 10 – SKELETAL SYSTEM
Yes No High Blood pressure Yes No Pain in arms and legs
Yes No Chest pain Yes No Limping
Yes No Heart defects Yes No Broken bones (which)
7 – GASTROINTESTINAL Yes No Joint swelling or pain
Yes No Frequent vomiting Yes No Congenital abnormality
Yes No Weight loss
Yes No Overweight
HS-10 FF 9-23-05 13