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ED 191

REV. 3/2015

Part II — Medical Evaluation

Health Care Provider must complete and sign the medical evaluation, physical examination and immunization record.

Child’s Name

Birth Date

Date of Exam

❑

(mm/dd/yyyy)

I have reviewed the health history information provided in Part I of this form

Physical Exam

Note: *Mandated Screening/Test to be completed by provider.

*HT

in/cm

*Weight

lbs.

oz /

BMI

*HC

in/cm

*Blood Pressure

(Birth – 24 months)

(Annually at 3 – 5 years)

Screenings

*Vision Screening

*Hearing Screening

*Anemia: at 9 to 12 months and 2 years

❑ EPSDT Subjective Screen Completed

(Birth to 3 yrs)

(Birth to 4 yrs)

❑ EPSDT Annually at 3 yrs

❑ EPSDT Annually at 4 yrs

(Early and Periodic Screening,

Diagnosis and Treatment)

*Hgb/Hct:

*Date

Type:

Right

Left

Type:

Right

Left

❑ Pass

*Lead: at 1 and 2 years; if no result

With glasses

20/

❑ Fail

screen between 25 – 72 months

❑ Fail

Without glasses

20/

❑ Unable to assess

History of Lead level

≥ 5

g/dL ❑ No ❑ Yes

❑ Referral made to:

❑ No ❑

❑ No ❑ Yes

*Result/Level:

*TB: High-risk group?

*Dental Concerns

*Date

❑ Referral made to:

Yes Test done: ❑ No ❑ Yes Date:

Other:

Results:

Has this child received dental care in

the last 6 months? ❑ No ❑ Yes

Treatment:

❑

*Developmental Assessment: (Birth – 5 years)

Yes

Type:

Results:

❑

IMMUNIZATIONS

Up to Date or

Catch-up Schedule: MUST HAVE IMMUNIZATION RECORD ATTACHED

*Chronic Disease Assessment:

❑ No

❑ Yes: ❑ Intermittent

❑ Mild Persistent

❑ Moderate Persistent

❑ Severe Persistent

❑ Exercise induced

Asthma

If yes, please provide a copy of an Asthma Action Plan

❑ Rescue medication required in child care setting:

❑ No ❑ Yes

❑ No

❑ Yes:

Allergies

❑ No

❑ Yes

Epi Pen required:

History/risk of Anaphylaxis: ❑ No ❑ Yes:

❑ Food ❑ Insects ❑ Latex ❑ Medication ❑ Unknown source

If yes, please provide a copy of the Emergency Allergy Plan

❑ No

❑ Yes: ❑ Type I

❑ Type II

Diabetes

Other Chronic Disease:

❑ No

❑ Yes: Type:

Seizures

❑ T his child has the following problems which may adversely affect his or her educational experience:

❑ Vision ❑ Auditory

❑ Speech/Language

❑ Physical ❑ Emotional/Social ❑ Behavior

❑ This child has a developmental delay/disability that may require intervention at the program.

❑ T his child has a special health care need which may require intervention at the program, e.g., special diet, long-term/ongoing/daily/emergency

medication, history of contagious disease. Specify:

❑ No ❑ Yes This child has a medical or emotional illness/disorder that now poses a risk to other children or affects his/her ability to participate

safely in the program.

❑ No ❑ Yes Based on this comprehensive history and physical examination, this child has maintained his/her level of wellness.

❑ No ❑ Yes This child may fully participate in the program.

❑ No ❑ Yes This child may fully participate in the program with the following restrictions/adaptation: (Specify reason and restriction.)

❑ No ❑ Yes Is this the child’s medical home? ❑ I would like to discuss information in this report with the early childhood provider

and/or nurse/health consultant/coordinator.

Signature of health care provider

Date Signed

Printed/Stamped Provider Name and Phone Number

MD / DO / APRN / PA

Early Childhood Health Assessment Record - State Of Connecticut Department Of Education Page 2

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