HS / EHS Child Health History


Child's Name:




Medical / Allergies

(Please initial here and skip this section)

(If Yes, an Allergy & Anaphylaxis Emergency Care Plan must be Completed Prior to Entry of Center)

Child Health History

* Care plan required to entry date

Child Birth History

Child's Birth Weight:


Developmental History


Social / Emotional Health


PLEASE READ AND INITIAL THE INFORMATION BELOW CAREFULLY

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.


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.