Health Appraisal

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Health Appraisal

Personal Information

Parent Information

  1. Allergies or Reactions (for example, food, medication or other)
  2. Hay Fever, Asthma, or Wheezing
  3. Eczema or Frequent Skin Rashes
  4. Convulsions/Seizures
  5. Heart Trouble
  6. Diabetes
  7. Frequent Colds, Sore Throats, Earaches (4 or more per year)
  8. Trouble with Passing Urine or Bowel Movements
  9. Shortness of Breath
  10. Speech Problems
  11. Menstrual Problems
  12. Dental Problems
  13. Other
Does your child take any medication(s) regularly?
Are there any current or past diagnosis(es)?
Was the health history reviewed by a health professional?