CHILD HEALTH ASSESSMENT
Name:______________________________________________
Birthdate:________________________________________
Address:____________________________________________
Birthplace:_______________________________________
Parent/Guardian:_____________________________________
Birth Certificate Number:____________________________
Address:____________________________________________
Phone: Work________________ Home_______________
In order to better serve the health needs of my child, I hereby give my permission for the transfer of health screening records to school and other
appropriate health professionals. Parent/Guardian Signature____________________________________________________ Date___________
HEALTH HISTORY:
To be filled out by parent or guardian
Yes
No
1. Are there any chronic illness problems in your family such as heart disease, diabetes,
cancer, convulsions or others?
___
___
2. Does any member of the family have a visual defect, hearing loss, or spinal deformity?
___
___
3. Were there any pre-natal or delivery problems with the child?
___
___
4. Did this child walk, talk, and speak at the usual time?
___
___
5. Does this child:
a. See a physician regularly for any illness problem?
___
___
b. Take any medication regularly?
___
___
c. Have a history of any hospitalization?
___
___
d. Have a history of menstrual problems? (if applicable)
___
___
e. Have a history of any childhood diseases?
___
___
f. Have a problem with vision, speech or hearing?
___
___
g. Have a problem with being shy or overactive?
___
___
h. Have any emotional problems?
___
___
i. Have any chronic illness or handicaps such as:
Yes
No
Yes
No
Yes
No
Headaches
___
___
Convulsions
___
___
Earaches
___
___
Colds/sore throat
___
___
Rheumatic Fever
___
___
Dental
___
___
Heart/Lung Disease
___
___
Allergies/Asthma
___
___
Urinary/Bowel ___
___
Back/Spine
___
___
Diabetes
___
___
Other
___
___
PHYSICAL EXAMINATION:
To be completed by physician or nurse approved to do health assessments
Height:___________
Weight:___________
Head____________________
Lungs:_____________________
CNS:_______________________
EENT:__________________
Breast:_____________________
Skin:_______________________
Dental:__________________
Abdomen:__________________
Lymphatic:__________________
Cardiovascular___________
G.U.:______________________
Musculoskeletal:______________
Screening Results:
Development (type of test)_________________________________________
Pulse_______________________
Hearing
Blood Pressure_______________
Right________ Left________
Hgb/HCT___________________
Vision
Urinalysis___________________
Right________ Left________
Sickle Cell__________________
Speech__________________________________________________
Other_______________________
Significant Assessment Findings:
Recommendations:
(include any special school needs)
Do you see this child for regular health supervision? Yes____
No____
Date:_______________________________
Signed:__________________________________Licensed Physician