1. Screening Results:
      2. Significant Assessment Findings:

                                                           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  

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