Kindergarten Health History Template - Multicare Associates
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4l Blaine Medical Center
11855 Ulysses St. NE, Blaine, MN 55434
763-785-4500
l Fridley Medical Center
480 Osborne Road NE, Fridley, MN 55432
l Roseville Medical Center
1835 County Rd C-West, Roseville, MN 55113
KINDERGARTEN HEALTH HISTORY
INDIVIDUAL HEALTH HISTORY
Date_________________
You have made an appointment for a complete Kindergarten physical on________________________
with __________________________. Please check in at ___________________________ .
Child’s Name_______________________________________________________________ Birthdate_________________
Parent’s Name__________________________________________Address_______________________________________
A. PREGNANCY & BIRTH
1. Did mother have any illness or rash during pregnancy with this child? . . . . . . . . . . . . . . . . . . .
YES
NO
If YES, specify the illness and month of pregnancy___________________________________
2. During this pregnancy, did mother have any symptoms such as:
High Blood Pressure
YES
NO
Vaginal Bleeding
YES
NO
Swelling of legs
YES
NO
Seizures
YES
NO
3. Did the baby come at the expected time of delivery? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
NO
YES
4. Did the mother have difficulty during labor and/or delivery? . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
5. What was the birth weight? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . LBS______ OZ.______
6. Did the baby have any trouble while in the hospital?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
7. Did the baby have any trouble starting to breathe? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
8. Did the baby go home with the mother? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
NO
YES
9. Was this pregnancy planned?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
NO
YES
B. HEALTH
1. Does this child feel well most of the time? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
NO
YES
2. In a year, has this child had as many as 3 episodes of ear trouble? . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
3. In a year, does this child usually have more than 3 colds or sore throat infections
with a fever? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
4. Has this child had any allergies or reaction to any medicines or injections? . . . . . . . . . . . . . . . .
YES
NO
5. Does this child complain frequently of headache, leg ache, stomach ache or
other pain? (circle) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
6. Has this child had trouble with his/her eyes or vision? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
7. Is this child’s appetite usually good? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
NO
YES
8. Do any foods disagree with this child? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
9. Does this child have any difficulty sleeping? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
10. Does this child have any problems with his/her teeth? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
11. Does this child chew unusual things such as pencils. cribs, window ledges,
paint chips, plaster or hair? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
12. Is this child taking any medicine now? (for example, aspirin, laxatives, etc?) . . . . . . . . . . . . . . . . .
YES
NO
If yes, please specify:__________________________________________________________
13. Does this child have trouble getting rid of severe cough? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
14. Circle any of the following diseases this child has had:“Red” or “Hard” Measles, German or
3 Day measles, Mumps, Meningitis, Pneumonia, Chickenpox, Scarlet Fever, Strep infections,
High Fever (Above 104°, for extended period of time)
MCA1158_0513
PED
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