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 Name
Last 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
*
Please Select
RUSH Next Business Day ($40 Fee)
7-10 Business Day ($10-$20 Fee)
How Would You Like To Receive Your Form?
*
Please Select
Pick-Up East Elizabeth Office Only
Deliver Electronically To Email
GENERAL HEALTH APPRAISAL FORM
Parent Please Complete, Date and Sign
Child's Name
*
Birthdate
*
/
Month
/
Day
Year
Date
Allergies
None
List Food/Medication
List Food/Medication
Diet
Breastfed
Age Appropriate
Special-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
/
Month
/
Day
Year
Date
Provider - Age
Provider - Weight
Provider - Physical Exam
Normal
Abnormal-Describe
Provider - Abnormal-Describe
Provider - Allergies
None
List Food/Medication
Provider - List Food/Medication
Provider - Type of Reaction
Provider - Current Medications
None
List
Provider - List
Provider - Current Diet
Breastfed
Age Appropriate
Special-describe
Provider - Special describe
Provider - Health Concerns
Severe Allergies
Asthma
Seizures
Diabetes
Hospitalizations
Behavior Concerns
Developmental Delays
Vision
Hearing
Oral Health
Under/Over Weight
Other
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
/
Month
/
Day
Year
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 Risk
Lead Level
Lead Level
TB
Not At Risk
Test Result Normal
Test Result Abnormal
Vision Screening
Vision Screening
Normal
Abnormal
Hearing
Hearing
Normal
Abnormal
Oral Health
Oral Health
Normal
Abnormal
Developmental Screen
ASQ
PEDS
Other
Developmental Screen Other
Developmental Concerns
Recommended Follow up
PROVIDER SIGNATURE
Next Well Visit
Per AAP Guidelines
Age
Age
Date
/
Month
/
Day
Year
Date
Submit
Should be Empty: