PART I - HEALTH ASSESSMENT
To be completed by parent or guardian
Child's Name:
First Name
Middle Initial
Last Name
Birth date:
-
Month
-
Day
Year
Date
Sex
M
F
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Name(s)
Relationship
Phone Number
Format: (000) 000-0000.
Parent/Guardian Name(s)
Relationship
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Medical Care Provider
Name:
Assessment of Child's Health - To the best of your knowledge has your child had any problem with the following? Check Yes or No and provide a comment for any yes answer.
Rows
Yes
No
Allergies
Asthma or Breathing
ADHD
Autism Spectrum Disorder
Behavioral or Emotional
Birth Defect(s)
Bladder
Bleeding
Bowels
Cerebral Palsy
Communication
Developmental Delay
Diabetes Mellitus
Ears or Deafness
Eyes
Feeding/Special Dietary Needs
Head Injury
Heart
Hospitalization (When, Where, Why)
Lead Poisoning/Exposure
Life Threatening/Anaphylactic Reactions
Limits on Physical Activity
Meningitis
Mobility-Assistive Devices if any
Prematurity
Seizures
Sensory Impairment
Sickle Cell Disease
Speech/Language
Surgery
Vision
Other
If answered Yes to Allergies
If answered Yes to Asthma or Breathing
If answered Yes to ADHD
If answered Yes to Autism Spectrum Disorder
If answered Yes to Behavioral or Emotional
If answered Yes to Birth Defect(s)
If answered Yes to Bladder
If answered Yes to Bleeding
If answered Yes to Bowels
If answered Yes to Cerebral Palsy
If answered Yes to Communication
If answered Yes to Developmental Delay
If answered yes to Diabetes Mellitus
If answered yes to Ears or Deafness
If answered Yes to Eyes
If answered Yes to Feeding/Special Dietary Needs
If answered Yes to Head Injury
If answered Yes to Heart
If answered Yes to Hospitalization (When, Where, Why)
If answered Yes to Lead Poisoning/Exposure
If answered Yes to Life Threatening/Anaphylactic Reactions
If answered Yes to Limits on Physical Activity
If answered Yes to Meningitis
If answered Yes to Mobility-Assistive Devices if any
If answered Yes to Prematurity
If answered Yes to Seizures
If answered Yes to Sensory Impairment
If answered Yes to Sickle Cell Disease
If answered Yes to Speech/Language
If answered Yes to Surgery
If answered Yes to Vision
If answered Yes to Other
Does your child take medication (prescription or non-prescription) at any time? and/or for ongoing health condition?
No
Yes, If yes, attach the appropriate OCC 1216 form.
Does your child receive any special treatments? (Nebulizer, EPI Pen, Insulin, Blood Sugar check, Nutrition or Behavioral Health Therapy /Counseling etc.)
No
Yes If yes, attach the appropriate OCC 1216 form and Individualized Treatment Plan
Does your child require any special procedures? (Urinary Catheterization, Tube feeding, Transfer, Ostomy, Oxygen supplement, etc.)
No
Yes, If yes, attach the appropriate OCC 1216 form and Individualized Treatment Plan
I GIVE MY PERMISSION FOR THE HEALTH PRACTITIONER TO COMPLETE PART II OF THIS FORM. I UNDERSTAND IT IS FOR CONFIDENTIAL USE IN MEETING MY CHILD'S HEALTH NEEDS IN CHILD CARE.
I ATTEST THAT INFORMATION PROVIDED ON THIS FORM IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE AND BELIEF.
Printed Name and Signature of Parent/Guardian
Date
-
Month
-
Day
Year
Date
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