Child’s Health History for Early/Head Start



Child’s NameDate of BirthAge:Gender:Preliminary Questions (please fill or circle yes/no)1.How much did your child weigh at birth: Weight Status at Birth:YesNo2. Has anyone in the family ever had any serious illnesses or abnormalities (e.g. heart disease, diabetes, cancer, tuberculosis, asthma, etc.) If yes, please explain:YesNo3. Were there any problems with this child immediately after birth? If yes, please explain:YesNo4. Is your child taking any medications every day? If yes, please explain:YesNo5. Will medication be needed at school? If yes, please explainHas your child ever had the following illnesses? If so, please give date and explain below: Measles Ear/Nose/Throat Problems Scarlet Fever Seizures Rheumatic Fever Heart Disease Mumps Urinary/Kidney Problems Respiratory Anemia Bee Sting Allergy Pneumonia ChickenpoxMuscle/BoneProblemsTuberculosis Blood Pressure Eye Problems Asthma Diabetes Intestinal ProblemsDates/Explanations:Has your child ever had the following? If yes, please give date and explain. HospitalizationsOperations Serious Injuries Other Health Problems/Illnesses Allergies to Medications (i.e. Penicillin, Sulfa Drugs)Developmental History: Did Child… Focus eyes and follow light or objects with eyes by 2 months? Coo and Gurgle by 3 to 4 months? Sit alone on or before the 8th month? Walk alone on or before the 15th month? Say simple words on or before the 2nd year? Toilet train on or before the 3rd year? Mental development appears normal?Immunization History (please check the one that applies for your child)Is child up to date on all immunizations appropriate for his/her age?Has child received all immunizations possible at this time but has not received all immunizations for his/her age?Has child received no immunizationsNone of the above. Explain/Comments:How often does your child eat these foods? Please check the number of times per day your child these foods.Food Groups0123456Milk Group: Milk (whole, 2%, 1%, skim), yogurt, cheese, milkshakes. Recommended: 3Meat, Poultry, Fish, Dry Beans, Eggs: Beef, chicken, turkey, pork, fish, eggs, peanut butter, Nut Group: dried beans, nuts, peas, lentils. Recommended: 2Bread, cereal, rice & pasta group: bread (all kinds), hot or cold cereal, crackers, tortillas, noodles or pasta (all kinds), rice. Recommended: 4Vitamin C Rich Group: Orange, grapefruit, lemon, lime, strawberries, tangerine, watermelon, mangoes, tomatoes, cabbage. Recommended: 1Other fruits and vegetables group: apple, banana, pear, grape, peach, potato, green beans, corn. Recommended: 3Vitamin A rich group (per week): Dark green or orange vegetables such as greens, carrots, broccoli, winter squash, spinach, pumpkin, sweet potato, apricots, canned plums, mangoes. Recommended: 3 per weekFatty foods: (a) bacon, lunch meat, sausage, hot dogs, fried foods (b) butter/margarine, sour cream, regular salad dressings, mayonnaiseSoda and flavored drinks: pop, kool aid, fruit drinksSugar and sweets: candies, cake, cookies, high sugar cerealsSalty snacks: chips, salted pretzels, picklesDental Information (please fill or circle yes/no)YesNoDo you have dental insurance? YesNoDoes the child have ongoing source of continuous and accessible dental care?YesNoWere there any problems for child? Comments:Dentist Name/Clinic:Nutrition Assessment (please fill or circle yes/no)YesNo Does your child’s weight appear normal?YesNoDoes your child eat fruits and vegetables?YesNoIs your child involved in active play dailyYesNoDoes your child have dental problems now?YesNoDoes your child have difficulty chewing or swallowing now?Food Substitution (please fill or circle yes/no)YesNoIs your child restricted from foods due to religious, vegetarian, medical or personal beliefs? If yes, please check all that apply:Pork Beef Poultry Fish Eggs Milk Other____________________YesNoDoes your child have any food allergies or intolerances? If yes, please check all that apply: Milk Milk Products Eggs All foods containing eggs Whole wheatWheat gluten Fish Shellfish Beef Legumes (dry beans/peas) Tree Nuts/seeds Peanuts Soybeans Vegetables ____________Fruits Juice ___________________ Other__________________________________What kind of reaction does your child have when your child eats the specified food? Life Threatening Rash Diarrhea Swelling Difficulty breathingOther________________________YesNoIs your child on any special diet prescribed by a doctor? If yes, please explain____________________________NOTE TO STAFF: If yes to questions 2, 3, and/or 4 above, parents must obtain physicians statement NOTE: Substitutions for non-medical reasons (i.e. religious, vegetarian, etc.) will be approved on a case-by-case basis with the Nutrition Manager or Nutritionist. Substitutions for medical reasons will be accommodated only with a signed statement from a licensed physician or other medical authority.Lead Poisoning Screening: (please fill or circle yes/no)YesNoIs paint peeling or chipping on any part of your houseYesNoIs your house being remodeled?YesNoHas your child or anyone in your family been treated or monitored for lead poisoning (blood level >10)YesNoDoes your child live with someone whose job or hobby involved exposure to lead (painting, soldering, automobile battery manufacturing or recycling, vehicle radiator repair, auto painting, or stained glass work)?YesNoDo you or anyone else who lives with or cares for your child use Azarcon, Greta, Rueda, Coral, Alcaron, Liga or Maria LuisiaYesNoDo you use pottery (ceramics, earthenware) that is old or has been bought outside the US for cooking, eating, drinking or storing food?YesNoDoes your family buy canned food or packed candies from other countriesYesNoDoes your child eat dirt or clay or other non-food itemsYesNoDoes your child or family frequently travel outside the US?Asthma/Allergy Screening (please fill or circle yes/no)YesNoHas your child ever been diagnosed by a medical professional as having asthma?Date of diagnosis _________________________________How many episodes per year_____________________________Is it seasonal? At what time of the year do the episodes most often occur________________Is it well controlled? How?YesNoHas your child experienced any of the following due to asthma? If yes, please check the ones that apply:Treatment in ER If yes, then # of times:______________________________Hospitalizations If yes, then # of times:______________________________YesNoHave you ever given your child any medication for asthma? If yes, please check all that you child has used in the last year? Albuterol Intal Ventolin Pedia Pred Tedral PreloneProventil Primitine Mist Marax Quiboron Other: __________YesNoDoes your child use a Nebulizer or Inhaler?YesNoHow many colds does your child have in a yearYesNoDoes your child suffer from hay fever or eczemaYesNoIs your child allergic to any of the following? If yes, please check all that apply:Animals Perfume Birds Pollen Grass Flowers DustTrees Smoke Weather changes Other:__________________YesNoDoes anyone in the household smoke (i.e. home/car)Medical Coverage (please fill or circle yes/no)YesNoDoes your family have a regular doctor or a regular place to receive health services? If yes, please answer the following:Doctor’s Name/Clinic Name:__________________________________Address:_________________________________________________Phone:_____________________________________________Date of last physical:________________________Primary Insurance: Medicaid All Kids or Kid Care Other:____________________________Health History Consent Section (please fill or circle yes/no)YesNoDental screening/exam and treatments (to detect problems with teeth or gums)YesNoBlood pressure screenings (if not noted on the physical examYesNoNutrition/growth screening and referral (to detect problems with delayed growth/overweight/underweight children)YesNoSpeech and language screenings: (to detect problems with speaking and understanding)YesNoDevelopmental screening (to assess levels in language, cognition, visual, small motor, gross motor, social and emotional aspects)YesNoBehavioral Observations (to further assess social and emotional development)YesNoIn cases of emergency medical/dental care, I give permission to Head Start staff to secure needed emergency medical care if parents/guardian cannot be immediately contacted YesNoThat necessary health information concerning my child may be released to the appropriate agencies assisting in the care of my child and the school my child will be attending after Head StartYesNoBlood test to check lead levels and/or anemia, if no results are availableYesNoVision Screening/exam to detect problems with vision and auditory/hearing screening (to detect problems with ears)Signed by Staff: _____________________________________________________________ Date: ______________________________Signed by Parent/Guardian: _____________________________________________ Date: _____________________________ ................
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