CAPE

HS / EHS Child Health History


Head Start Center:

Classroom Number:

Child's Name: ,

Sex:   DOB:
Name of Mother: Name of Father:
Phone Number:
Child has Medicaid:
Child has Private Health Insurance:
Medicaid / Policy Number:
Medicaid Plan Name:
Is your child on WIC?
Physician's Name: Phone Number:
Physician Specialist: Phone Number:

Medical / Allergies


Is your child taking any medications? Medication Names:
Has your child been hospitalized within the past 12 months? Has the doctor prescribed an EpiPen?
Does your child have allergies?
Physician documentation can be obtained for allergies: (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?

If yes, please describe:

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

Child Birth History

Child's Birth Weight: lbs oz Was Birth Premature? Any Illness or Complications?
If so, please describe:

Developmental History

Please list any tasks your child has difficulty demonstrating:

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?

Does your child need help with the bathroom?

Does your child tend to worry a lot?

Does your child have an IEP / IFSP? If yes, write provider name here:


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 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.

Leave this empty:

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Signature Certificate
Document name: HS / EHS Child Health History
lock iconUnique Document ID: 9ce93932d9429b33e2c377881538c97d7553366c
Timestamp Audit
April 16, 2021 10:25 am CDTHS / EHS Child Health History Uploaded by Joe Massaro - jmassaro@capeevansville.org IP 96.27.254.146