Early Childhood Health Assessment Record - State Of Connecticut Department Of Education

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State of Connecticut Department of Education
Early Childhood Health Assessment Record
(For children ages birth – 5)
To Parent or Guardian: In order to provide the best experience, early childhood providers must understand your child’s health needs. This form
requests information from you (Part I) which will be helpful to the health care provider when he or she completes the health evaluation (Part II). State
law requires complete primary immunizations and a health assessment by a physician, an advanced practice registered nurse, a physician assistant, or a
legally qualified practitioner of medicine, an advanced practice registered nurse or a physician assistant stationed at any military base prior to entering
an early childhood program in Connecticut.
Please print
Child’s Name
Birth Date
Male
Female
(Last, First, Middle)
(mm/dd/yyyy)
Address
(Street, Town and ZIP code)
Home Phone
Cell Phone
Parent/Guardian Name
(Last, First, Middle)
Early Childhood Program
Race/Ethnicity
(Name and Phone Number)
American Indian/Alaskan Native
Hispanic/Latino
Primary Health Care Provider:
Black, not of Hispanic origin
Asian/Pacific Islander
White, not of Hispanic origin
Other
Name of Dentist:
Health Insurance Company/Number* or Medicaid/Number*
Does your child have health insurance?
Y
N
If your child does not have health insurance, call 1-877-CT-HUSKY
Does your child have dental insurance?
Y
N
Does your child have HUSKY insurance? Y
N
* If applicable
Part I — To be completed by parent/guardian.
Please answer these health history questions about your child before the physical examination.
Please circle Y if “yes” or N if “no.” Explain all “yes” answers in the space provided below.
Any health concerns
Y
N
Frequent ear infections
Y
N
Asthma treatment
Y
N
Allergies to food, bee stings, insects Y
N
Any speech issues
Y
N
Seizure
Y
N
Any problems with teeth
Allergies to medication
Y
N
Y
N
Diabetes
Y
N
Any other allergies
Y
N
Has your child had a dental
Any heart problems
Y
N
examination in the last 6 months
Y
N
Any daily/ongoing medications
Y
N
Emergency room visits
Y
N
Any problems with vision
Y
N
Very high or low activity level
Y
N
Any major illness or injury
Y
N
Uses contacts or glasses
Y
N
Weight concerns
Y
N
Any operations/surgeries
Y
N
Any hearing concerns
Y
N
Problems breathing or coughing
Y
N
Lead concerns/poisoning
Y
N
Sleeping concerns
Y
N
Developmental — Any concern about your child’s:
High blood pressure
Y
N
1. Physical development
Y
N
5. Ability to communicate needs
Y
N
Eating concerns
Y
N
6. Interaction with others
Y
N
2. Movement from one place
Toileting concerns
Y
N
to another
Y
N
7. Behavior
Y
N
3. Social development
Y
N
8. Ability to understand
Y
N
Birth to 3 services
Y
N
4. Emotional development
Y
N
9. Ability to use their hands
Y
N
Preschool Special Education
Y
N
Explain all “yes” answers or provide any additional information:
Have you talked with your child’s primary health care provider about any of the above concerns? Y
N
Please list any medications your child
will need to take during program hours:
All medications taken in child care programs require a separate Medication Authorization Form signed by an authorized prescriber and parent/guardian.
I give my consent for my child’s health care provider and early
childhood provider or health/nurse consultant/coordinator to discuss
the information on this form for confidential use in meeting my
Signature of Parent/Guardian
Date
child’s health and educational needs in the early childhood program.
ED 191 REV. 3/2015
C.G.S. Section 10-16q, 10-206, 19a.79(a), 19a-87b(c); P.H. Code Section 19a-79-5a(a)(2), 19a-87b-10b(2)

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