River Edge Elementary Schools 410 Bogert Road, River Edge, New Jersey 07661

201-261-3404 Fax 201-261-0698 www.riveredgeschools.org

“Building Bright Futures Together”

Dr. Tova Ben-Dov Louise Napolitano Superintendent of Schools Business Administrator/Board Secretary

Health History Form Demographics Child’s Name: ___________________________________________Gender: M F Phone #: ________________________ Place of Birth: __________________ Birth Date: ________ Primary Language: ____________________ Secondary Language: ______________________________ Address: ____________________________________________________________________________ Parent/Guardian Name: ______________________ Parent/Guardian Name: _____________________ Relationship to Child: ________________________ Relationship to Child: _______________________ Siblings: Name: ___________________________ Age: ____________ Grade: ____________ Name: ___________________________ Age: ____________ Grade: ____________ Name: ___________________________ Age: ____________ Grade: ____________ Child’s Physician Name: __________________________ Phone #: __________________________ Hospital Preference: _____________________________ Dentist’s Name:_________________________________ Phone #: __________________________ Developmental History Did you notice any delay or abnormal behavior in your child’s early growth years? Yes No ____________________________________________________________________________________ ____________________________________________________________________________________ Medical History of Child Any history of head injuries, head trauma, or any diseases of the Brain? Yes No If yes, explain: ____________________________________________________________________________________ Any Hospitalizations for an Operation, Accident, or Medical Illness? Yes No If yes, explain:_________________________________________________________________________ Allergies: Food: __________________________________________________________________________ Type of Reaction: _______________________________________ Last Occurrence: ___________

Medication: _____________________________________________________________________ Type of Reaction: _________________________________________________________________

Health History Form (Page 2)

Pollen/Seasonal Allergies? Yes No Type of reaction: ________________________________ Bee Sting Allergy? Yes No Reaction: ___________________________________________ Allergy to Animals? Yes No Reaction: ___________________________________________ Other Allergies? __________________________________________________________________ History of Illnesses: Check all that apply: ASTHMA BRONCHITIS CANCER EAR INFECTION EAR TUBES DIABETES ECZEMA SKIN DISORDERS SEIZURES/CONVULSIONS HEARTDISEASE OTHERS: ________________________________________________________________________ Is your child on any medications? Yes No Medication: __________________________________ Reason: ___________________________ Medication: __________________________________ Reason: ___________________________ Does your child wear glasses or contact lens? Yes No Any problems with: SPEECH VISION HEARING PHYSICAL LIMITATIONS Explain: _________________________________________________________________________ ADDITIONAL COMMENTS OR CONCERNS ABOUT YOUR CHILD: ________________________________________________________________________________

Signature/Release of Information:

As parent/Guardian of _______________________________, I hereby authorize the release of pertinent medical information about my child to those professional staff involved in his/her care or instruction. This consent is valid in the River Edge Public School District and may be revoked by myself at anytime in writing.

____________________________________ __________________________________ _______

SIGNATURE PRINT NAME DATE