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HS / EHS Child Health History

Web Site

Head Start Center: *

Classroom Number: *

Child's Name:

Last *

First *

Middle *

Sex: *

Male Female

Date of Birth: *

Name of Mother: *

Name of Father: *

Phone Number: *

Child has Medicaid: *

Yes No

Child has Private Health Insurance: *

Yes No

Child is on WIC: *

Yes No

Medicaid / Policy Number:

Medicaid Plan Name:

Physician's Name: *

Physician's Phone Number: *

Physician Specialist:

Specialist's Phone Number:

Medical / Allergies

Has allergies checkbox

My child has NO health or NO allergy concerns at this time

Parent / Guardian Initial:

(Please initial here and skip this section)

Is Your Child Taking Any Medications?

Yes No

Medication Names:

Has Your Child Been Hospitalized Within the Past 12 Months?

Yes No

Has the Doctor Prescribed an EpiPen?

Yes No

Does Your Child Have Allergies?

Seasonal / Environmental Food Insect

Physician Documentation can be Obtained for Allergies:

Yes No (If Yes, an Allergy & Anaphylaxis Emergency Care Plan must be Completed Prior to Entry of Center)

Child Health History

Has your child had any illness or hospitalization since birth?

Yes No

If yes, please describe:

Please select all health problems your child has been diagnosed with or had the following conditions:

Asthma / Respiratory *

Oral Health Issue

Blindness / Vision

Wears Glasses

Bone Defect

Cerebral Palsy

Frequent Sore Throat

Fainting Spells

Hearing / Deafness

Diabetes *

Heart Trouble

Learning

Speech

Seizures / Epilepsy *

Intestinal Problems

Skin Problems

Sickle Cell

ADD / ADHD

Frequent Bed Wetting

* Care plan required to entry date

Other:

Child Birth History

Child's Birth Weight:

Pounds

Ounces

Was Birth Premature?

Yes No

Any Illness or Complications?

Yes No

If so, please describe:

Developmental History

Please select below if your child demonstrates any difficulties with the following tasks:

Sitting up without help

Talking

Responding to directions

Crawling

Feeding Self

Walking

Using Crayons

Toilet training

Playing with toys

Social / Emotional Health

What are one or two things your child is interested in or does especially well?

Do you have any concern about how your child expresses his / her emotions?

Yes No

Does your child need help with the bathroom?

Yes No

Does your child tend to worry a lot?

Yes No

Does your child have an IEP / IFSP?

Yes No

If yes, write provider name here:

PLEASE READ AND INITIAL THE INFORMATION BELOW CAREFULLY

Permission 1

I give permission I do not give permission

Parent / Guardian Initial

for my child to receive Developmental, Speech / Language, Hearing, Vision, and Social / Emotional screening during the first 45 days of the school year.
The screening is to determine if further evaluation is necessary.

Permission 2

I give permission I do not give permission

Parent / Guardian Initial

for my child to be tested for lead, and agree to complete the e-consent for the County Health Department to administer a blood lead test, if necessary. The parent will be notified of screening results. Lead results / tests may also be obtained through my primary care physician.

County *

Parent / Guardian Name *

Parent / Guardian Email *

All services are provided without regard to race, age, color, religion, sex, disability, national origin, ancestry, or status as a veteran.

CAPE is an equal opportunity employer and does not discriminate on the basis of race, color, national origin, sex, age or disability.

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