General Health Appraisal Form

Form Completion Information

Please complete the information below indicating your contact information, relationship to patient, how you would like to receive your form and you preferred method of delivery.
Person Requesting Form*

First NameLast Name
Relationship To Patient*
Contact Phone*
Please enter a valid phone number.
Contact Email*
example@example.com
Please Select When You Would Like Your Form Returned*
How Would You Like To Receive Your Form?*
GENERAL HEALTH APPRAISAL FORM

Parent Please Complete, Date and Sign
Child's Name*
Birthdate*

MonthDayYear
Date
Allergies

NoneList Food/Medication
List Food/Medication
Diet

BreastfedAge AppropriateSpecial-Describe
Special-Describe
Skin Care

Sunscreen/cream may be applied as requested in writing by parent unless skin is broken or bleeding
HEALTH CARE PROVIDER
Provider - Date of most recent health appraisal

MonthDayYear
Date
Provider - Age
Provider - Weight
Provider - Physical Exam

NormalAbnormal-Describe
Provider - Abnormal-Describe
Provider - Allergies

NoneList Food/Medication
Provider - List Food/Medication
Provider - Type of Reaction
Provider - Current Medications

NoneList
Provider - List
Provider - Current Diet

BreastfedAge AppropriateSpecial-describe
Provider - Special describe
Provider - Health Concerns

Severe AllergiesAsthmaSeizuresDiabetesHospitalizationsBehavior ConcernsDevelopmental DelaysVisionHearingOral HealthUnder/Over WeightOther
Provider - Other
Explain above concerns (if necessary, include instructions to care providers)
Immunizations

See Attached Immunization Record
Next Vaccine Date

Next Vaccine Due Date
Next vaccine due date

MonthDayYear
Date
HEALTH CARE PROVIDER

Please complete if appropriate. This information is required by Early Head start and Head Start Programs per the state EPSDT Schedule.
Height
B/P
Head Circumference (up to 12 months)
HCT/HGB
Lead Level

Not At RiskLead Level
Lead Level
TB

Not At RiskTest Result NormalTest Result Abnormal
Vision Screening

Vision ScreeningNormalAbnormal
Hearing

HearingNormalAbnormal
Oral Health

Oral HealthNormalAbnormal
Developmental Screen

ASQPEDSOther
Developmental Screen Other
Developmental Concerns
Recommended Follow up
PROVIDER SIGNATURE
Next Well Visit

Per AAP GuidelinesAge
Age
Date

MonthDayYear
Date
Should be Empty:

Form Completion Information

GENERAL HEALTH APPRAISAL FORM

HEALTH CARE PROVIDER

HEALTH CARE PROVIDER

PROVIDER SIGNATURE