Child Health Assessment
Parent/legal guardian and teachers/child care providers ﬁll in this part.
CHILD’S NAME (LAST) (FIRST) PARENT/GUARDIAN
DATE OF BIRTH HOME PHONE ADDRESS
CHILD CARE FACILITY NAME
FACILITY PHONE COUNTY WORK PHONE
To parents: Be sure to sign a consent form for your child’s teachers/caregivers and one for your child’s health care professional to share information
about your child’s health with one another.
This facility requires that children who are enrolled in a group care setting have received age-appropriate preventive health services, including
screenings and immunizations that meet the current recommendations of the American Academy of Pediatrics. This schedule is available on the
Internet at http://pediatrics.aappublications.org/content/suppl/2007/12/03/120.6.1376.DC1/Preventive_Health_Care_Chart.pdf.
HEALTH HISTORY AND MEDICAL INFORMATION PERTINENT TO ROUTINE CHILD CARE AND EMERGENCIES DATE OF MOST RECENT WELL-CHILD EXAM
(DESCRIBE, IF ANY)
This form may be updated (instead of completing a
o NONE new form) at each checkup visit by the child’s health
ALLERGIES TO FOOD OR MEDICINE (DESCRIBE IF ANY) care professional with dated, initialed notes or by
attaching a printout of an electronic medical record
Parents may write immunization dates; health professionals should verify and complete all data.
LENGTH/HEIGHT WEIGHT BMI BLOOD PRESSURE
, % , % , % (Beginning at age 3)
PHYSICAL EXAMINATION ü+ IF ABNORMAL—COMMENTSNORMAL
NEUROLOGIC & DEVELOPMENTAL