HS / EHS Child Health History
Head Start Center:
Child's Name: ,
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:
Please list any tasks your child has difficulty demonstrating:
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:
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:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: HS / EHS Child Health History
Agree & Sign