Health History - Highline Public Schools

Health History - Highline Public Schools

Health History
HealthPoint - School Based Health Center
FAMILY HISTORY (Please provide information on biological family only.)
Were you adopted? Yes  No
Mother’s birthdate: __________
Father’s birthdate: __________
Mother’s age: _____
Father’s age: _____
Living? Yes  No
Living? Yes  No
Please indicate who in your family has been diagnosed with any of the following (e.g. mother, father, grandparents, siblings, etc.):
ADD/ADHD_____________________________________________
Allergies _______________________________________________
Asthma ________________________________________________
Cancer ________________________________________________
Hip dysplasia ____________________________________________
Deafness_______________________________________________
Depression _____________________________________________
Development delay _______________________________________
Diabetes _______________________________________________
High cholesterol _________________________________________
Eczema ________________________________________________
High blood pressure ______________________________________
Learning disability ________________________________________
Mental retardation ________________________________________
Obesity ________________________________________________
Migraines ______________________________________________
Scoliosis _______________________________________________
Seizure disorder _________________________________________
Sickle cell disease ________________________________________
Strabismus/lazy eye ______________________________________
Sudden death ___________________________________________
Other __________________________________________________
SOCIAL HISTORY
Primary residence:  Mother  Father  Other
Secondary residence:  Mother  Father  Other
Tobacco use:  Yes  No  Before
Smokers in family:  Yes  No
Smoking allowed in home:  Yes  No
Mother’s occupation: _____________________________________
Father’s occupation: _____________________________________
Parents’ relationship: ____________________________________________________________________________________________________
Child cooperates with family/friends?  Yes  No
Cooperates with teachers?  Yes  No
Has enough friends?  Yes  No
Has friends of both genders?  Yes  No
Concerns about relationship with family/friends/other?  Yes  No
Home type:  Apartment  House  Condominium  Mobile home (trailer)
Year home was built: __________
Water source:  Municipal  Well
Do you have the following at home?
Carbon monoxide detectors:  Yes  No
Pets/animals:  Yes  No
Smoke detectors:  Yes  No
Firearms:  Yes  No
PERSONAL HEALTH HISTORY
Mark all that apply and write in date of onset:
 Allergy _________________________
 Anemia _________________________
 Arthritis _________________________
 Asthma _________________________
 Diabetes ________________________
 Hepatitis ________________________
 Tuberculosis _____________________
 Ulcer ___________________________
 Seizures ________________________
 Impotence ______________________
 Stroke __________________________
 Bronchitis _______________________
 Nervous system/brain disease
__________________________________
 Sexually transmitted diseases/pelvic
infections __________________________
 Back problems ___________________
 Bleeding problems ________________
 Bone problems ___________________
 Bowel problems __________________
 Cancer/tumor ____________________
 Changing mole ___________________
 Depression/anxiety _______________
 Ear/hearing problems ______________
 Eye/vision problems _______________
 Hay fever _______________________
 Headaches ______________________
 Head injuries ____________________
 Heart disease
 High blood pressure _______________
 Kidney stones ___________________
 Kidney/urine infections _____________
 Mental illness ____________________
 Neck problems ___________________
 Prostate problems ________________
 Serious infections _________________
 Skin problems ___________________
 Stomach problems ________________
 Swollen glands ___________________
 Thyroid problems _________________
 Urine problems ___________________
 Other __________________________
For women only ~
Age of first period: _____ Last menstrual period: __________ Any menstrual problem?  Yes  No
Method of birth control: ________________________________
SBHC Health History
Orig 9/11/12
Health History
HealthPoint - School Based Health Center
HISTORIAL FAMILIAR (Información solo de su familia biológica por favor.)
Es usted adoptado(a)?  Si  No
Fecha de nacimiento de la madre: __________ Edad de la madre: _____
Fecha de nacimiento del padre: ____________ Edad del padre: _______
Viva?  Si  No
Vivo?  Si  No
Por favor señalar quién en su familia ha sido diagnosticado con lo siguident (madre, padre, abuelos, hermanos, etc.):
Trastorno Deficitario de la Atención __________________________
Alergias ________________________________________________
Asma __________________________________________________
Cáncer ________________________________________________
Displasia de la cadera _____________________________________
Sordera ________________________________________________
Depresión ______________________________________________
Desarrollo retardado ______________________________________
Diabetes _______________________________________________
Colesterol alto ___________________________________________
Eczema ________________________________________________
Presión alta _____________________________________________
Discapacidad de aprendizaje _______________________________
Retraso mental __________________________________________
Obesidad _______________________________________________
Migrañas _______________________________________________
Escoliosis ______________________________________________
Convulsiones ___________________________________________
Drepanocitosis __________________________________________
Estrabismo/Ojo Desviado __________________________________
Muerte Súbita ___________________________________________
Otro ___________________________________________________
HISTORIAL SOCIAL
Domicilio principal:  Madre  Padre  Otro
Domicilio secundario:  Madre  Padre  Otro
Uso de tabaco?  Si  No  Antes
Fumadores en la familia?  Si  No
Se permite fumar en la casa?  Si  No
Ocupación(es) de la madre: ________________________________
Ocupación(es) del padre: __________________________________
Relación de los padres: ___________________________________________________________________________________________________
Niño(a) coopera con la familia/amigos?  Si  No
Coopera con los maestros?  Si  No
Tiene suficientes amigos?  Si  No
Tiene amigos y amigas?  Si  No
Le preocupa la relación con la familia/amigos/otros?  Si  No
Tipo de hogar:  Apartamento  Casa  Condominio  Trailer
Año que se construyó el hogar: __________
Fuente del agua:  Municipal  Pozo
Hay lo siguiente en el hogar?
Detectores de monoxide de carbono:  Si  No
Mascotas/animals:  Si  No
Detectores de humo :  Si  No
Armas:  Si  No
HISTORIAL PERSONAL DE LA SALUD
Marque todos los que correspondan y escriba la fecha de aparición:
 Alergias ________________________
 Enfermedades transmitidas
 Anemia _________________________
sexualmente infecciones
 Atritis___________________________
pélvicas/EPI________________________
 Asma __________________________
 Probelmas de la espalda ___________
 Diabetes ________________________
 Problemas de hemorragia __________
 Hepatitis ________________________
 Problemas a los huesos/articulaciones
 Tuberculosis _____________________
__________________________________
 Ulcera __________________________
 Problemas intestinales _____________
 Convulsiones ____________________
 Lunar cambiante _________________
 Impotencia ______________________
 Depresión/ansiedad _______________
 Derrame cerebral _________________
 Problemas de audición/oídos ________
 Bronquitis _______________________
 Problemas de visión/ojos ___________
 Sistema nervioso/enfermedades del
 Fiebre de heno ___________________
cerebro ___________________________
 Dolores de cabeza ________________
 Lesiones a la cabeza ______________
 Cáncer/Tumor____________________
Sólo para mujeres~
Edad del primer periodo menstrual: _____
Ultimo periodo menstrual: __________
Método anticonceptivo: ___________________________________________________
 Enfermedad al corazón ____________
 Presión alta _____________________
 Cálculos renales _________________
 Infecciones de los riñones/de la orina
__________________________________
 Enfermedad mental _______________
 Problemas al cuello _______________
 Problemas a la prostate ____________
 Infecciones graves ________________
 Problemas en la piel ______________
 Problemas estomacales ____________
 Glándulas inflamadas _____________
 Problemas con la tiroides ___________
 Problemas de orina _______________
 Otro ___________________________
Algún problema menstrual?  Si  No
SBHC Health History Orig 9/11/12