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Interval Health Form


LEVERETT ELEMENTARY SCHOOL

INTERVAL HEALTH HISTORY


STUDENT'S NAME____________________________TEACHER____________________GRADE_________


Please fill out the information below. Please provide health information that is new since the last Interval

Health History was completed or since the end of the last school year. Please include a copy of your child’s

updated physical exam and immunizations. Thank you.


Date of Last PHYSICAL Exam_______________________ Doctor’s Name____________________________

Date of Last DENTAL Exam ________________________ Dentist’s Name____________________________

Date of Last HEARING Exam _______________________ Where__________________________________

Date of Last VISION Exam _________________________Where__________________________________

Date of Last POSTURAL SCREENING_________________ Where__________________________________


Please explain and give dates for the following.

Accidents______________________________________________________________________________

Hospitalizations__________________________________________________________________________

Surgery________________________________________________________________________________

Broken bones____________________________________________________________________________

Asthma/lung problems_____________________________________________________________________

Kidney problems__________________________________________________________________________

Heart problems/murmurs___________________________________________________________________

Ear infections___________________________________________________________________________

Frequent headaches_______________________________________________________________________

Date your daughter began menstruating and are there any menstrual problems?___________________________

Communicable diseases (specify) _____________________________________________________________

Dental problems__________________________________________________________________________

Seizures _______________________________________________________________________________

Diabetes _______________________________________________________________________________

Allergic reactions________________________________________________________________________

What medicines does your child take? _________________________________________________________

______________________________________________________________________________________

(Note: Medications CANNOT be given at school without written orders from your child's physician.)

Does your child have any present physical limitations that may require program modification or restrictions?

Yes No Explain_________________________________________________________________

Has there been any change in your child’s living environment? (Moved, marriage/living together/separation/divorce,

birth of sibling, family illness, etc.)___________________________________________________________

Tell me if your child has any dietary restrictions due to medical allergies or religious beliefs. ________________

______________________________________________________________________________________

Are there any other concerns or comments you would like to bring to my attention? _______________________

______________________________________________________________________________________

______________________________________________________________________________________

I give permission to the school nurse to share information relative to my child’s medical health with appropriate

school personnel. YES NO Are there any restrictions on information shared? __________________

______________________________________________________________________________________

DATE _________________ SIGNATURE _____________________________________________

(Parent or Guardian)