CHILD HEALTH ASSESSMENT

Screening Results:
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