II. MEDICAL HISTORY
Name of Examinee
Does your child currently, or have a hisory of:
30. Is there anything else you would like to add about your child's health or well being that was not addressed in questions 1-29?
V. SIGNATURE OF PARENT OR SPONSOR (I certify I have read and understand the above statement.)
1. Frequent/severe headaches?
2. Fainting or dizzy episodes?
III. LIST OF CURRENT MEDICATIONS (Include prescription, over the counter, vitamins, and herbs)
Drug Or Other Allergies
IV. HOSPITALIZATIONS/OPERATIONS/MEDICAL EVACUATIONS (Include all medical and psychiatric illnesses)
Illness or Operation
Name of Hospital
City and State
Any knowing and willful omission, falsification, or fraudulent statement regarding material medical information may constitute a criminal
offense under 18 U.S.C. § 1001, and individuals committing such an offense may be subject to criminal prosecution. Employees of the
United States Government also may be subject to disciplinary action, up to and including separation, for any knowing and willing omission
or falsification or fraudulent statement of material information.
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PLEASE ANSWER THE FOLLOWING QUESTIONS: For YES answers, provide a brief explanation, attach additional sheets, if needed.
II a. Explanation required for "yes" answers to questions 1-30. Attach additional sheets as needed
3. Seizures or neurologic disorders?
4. Chronic eye or vision problems?
5. Ear, nose, or throat problems, including hearing loss?
6. Allergies or history of anaphylactic reaction?
7. Cough, wheeze, shortness of breath, asthma?
8. Heart murmur or heart problems?
9. Rheumatic fever?
10. Diabetes or thyroid disorder?
11. Hormonal or metabolic disorder?
12. Stomach, esophageal, intestinal problems?
13. Liver or gallbladder problems. Hepatitis?
14. Intestinal, rectal problems or hernia?
16. Blood transfusions?
17. Urinary or kidney problems, blood in urine?
18. Cancer of any type?
19. Joint, tendon or any orthopedic disorder?
20. Rheumatologic or immune disorder?
21. Malaria or other tropical disease?
22. Any recent unexpected weight loss/gain?
23. Any skin or nail disorder
24. History of Tuberculosis TB exposure?
25. Has your child been referred for any current or
potential special educational services, accommodations, or
modifications (i.e.: IFSP, Early Intervention, IEP, 504 Plan)?
26. In the past seven years, has your child been in
psychotherapy/counseling or been prescribed medication to help with
depression, anxiety, mood or stress?
27. Has your child felt unusually depressed, sad, blue, or
had frequent crying spells which lasted more than 2 weeks at a time,
within the past seven years?
28. In the past seven years, has your child had frequent or
recurrent episodes of: difficulty relaxing or calming down, panicky
feelings, irritability, anger, feeling hyper, or nervousness?
29. In the past seven years, has your child experienced
any emotional or physical symptoms related to a past trauma?
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