CHILD HEALTH ASSESSMENT FORM
PARENT/PROVIDER FILL IN THIS PART
PARENT/GUARDIAN NAME
First
Last
WORK PHONE
Please enter a valid phone number.
Format: (000) 000-0000.
ADRESS
Adress Line 1
Adress Line2
County
City
Postal Code
CHILD'S NAME
First
Last
DATE OF BIRTH
-
Ay
-
Gün
Yıl
1
HOME PHONE
Please enter a valid phone number.
Format: (000) 000-0000.
CHILD CARE FACILITY NAME
FACILITY PHONE
Please enter a valid phone number.
Format: (000) 000-0000.
CONFIRMATION TEXT
I authorize the child care staff and my child’s health professional to communicate directly if needed to clarify information on this form about my child.
PARENT’S SIGNATURE
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DO NOT OMIT ANY INFORMATION
This form may be updated by a health professional. Initial and date any new data. The child care facility needs a copy of the form.
LENGTH
CM
WEIGHT
KG
HEAD CIRCUMFERENCE
CM
BLOOD PRESSURE
Blood pressure is recorded with 2 numbers.
HEALTH HISTORY AND MEDICAL INFORMATION PERTINENT TO ROUTINE CHILD CARE AND DIAGNOSIS/TREATMENT IN EMERGENCY
NONE
DESCRIBE, IF ANY:
DESCRIBE ALL MEDICATION AND ANY SPECIAL DIET THE CHILD RECEIVES AND THE REASON FOR MEDICATION AND SPECIAL DIET. ALL MEDICATIONS ACHILD RECEIVES SHOULD BE DOCUMENTED IN THE EVENT THE CHILD REQUIRES EMERGENCY MEDICAL CARE. ATTACH ADDITIONAL SHEETS IF NECESSARY.
NONE
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CHILD’S ALLERGIES
NONE
DESCRIBE, IF ANY:
LIST ANY HEALTH PROBLEMS OR SPECIAL NEEDS AND RECOMMENDED TREATMENT/SERVICES. ATTACH ADDITIONAL SHEETS IF NECESSARY TODESCRIBE THE PLAN FOR CARE THAT SHOULD BE FOLLOWED FOR THE CHILD, INCLUDING INDICATION OF SPECIAL TRAINING REQUIRED FOR STAFF,EQUIPMENT AND PROVISION FOR EMERGENCIES.
NONE
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IN YOUR ASSESSMENT, IS THE CHILD ABLE TO PARTICIPATE IN CHILD CARE AND DOES THE CHILD APPEAR TO BE FREE FROM CONTAGIOUS ORCOMMUNICABLE DISEASES?
YES
NO
IF NO, PLEASE EXPLAIN YOUR ANSWER
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PHYSICAL EXAMINATION
PLEASE WRITE THE PHYSICAL EXAMINATION INFORMATION CORRECTLY.
Rows
NORMAL
If ABNORMAL - COMMENTS
Head/Ears/Eyes/Nose/Throat
2
Teeth
3
Cardiorespiratory
4
Abdomen/GI
5
Genitalia/Breasts
6
Extremities/Joints/Back/Chest
7
Skin/Lymph Nodes
8
Neurologic & Developmental
9
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IMMUNIZATIONS
RECORD DATES OF IMMUNIZATIONS BELOW OR ATTACH A PHOTOCOPY OF THE CHILD’S IMMUNIZATION RECORD
Rows
DATE
DATE
DATE
DATE
DATE
COMMENTS
DTa/DTP/Td
POLIO
HIB
HEP B
MMR
VARICELLA
PNEUMOCOCCAL
INFLUENZA
ROTAVIRUS
RECORD PHOTOCOPY
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SCREENING TESTS
FILL IN THE SCREENING TEST INFORMATION
Rows
DATE TEST DONE
NOTE HERE IF RESULTS ARE PENDING OR ABNORMAL
LEAD
ANEMIA (HGB/HCT)
URINALYSIS (UA) (at age 5)
HEARING (subjective until age 4)
VISION (subjective until age 3)
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HEALTH PROBLEMS OR SPECIAL NEEDS, RECOMMENDED TREATMENT/MEDICATIONS/SPECIAL CARE
NONE
YOU CAN WRITE EXTRA INFORMATION HERE...
MEDICAL CARE PROVIDER
PHONE NUMBER
Please enter valid phone number...
Format: (000) 000-0000.
CARE PROVIDER ADDRESS
Adress Line 1
Adress Line 2
County
City
Postal Code
NEXT APPOINTMENT - MONTH/YEAR
LICENSE NUMBER
SIGNATURE
DATE FORM SIGNED
-
Ay
-
Gün
Yıl
Date
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