Health Screen Form
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1
2Date: ___________
Child’s Name: ____________________________Your Relationship to Child:______________________Date of Birth:_________
Height:__________________ Weight:________________ Date of M
easurement: __________________Gender:
Male
Female
Height and Weight ob
If your child has a history of any of these health issues, please check and describe them below. This is not a complete list of conditions, signs or symptoms.
History of the following:
Description/Concern/Ability to Self-Manage
Y
N
1.
Bones or Joints
Bone or joint pain, arthritis, broken bones
2.
Brain or Neurological
Seizures, tremors, paralysis, past trauma that is causing current
concerns (concussion)
3.
Cancer
4.
Dental or Oral Health
Date of last exam:_______
Any concerns, braces or retainers needed, loose teeth
5.
Diabetes and last
HbA1C (a lab that shows the average level of
blood sugars over the previous three months and how well it has been
controlled.)
6.
Ears or Hearing
Date of last exam:_______
Any concerns, hearing aids needed, ringing in ears, tubes in ears
7.
Eating, Digestion, or Bowel
Change in or poor appetite, GERD
(digestive disease that occurs when
stomach acid or, bile flows back into your food pipe, the esophagus)
or
reflux, heartburn, nausea/vomiting, constipation, diarrhea, ulcers,
laxative use, eating disorders, changes in stool
8.
Does your child have any special nutritional needs or is
child at risk nutritionally?
Has doctor prescribed vitamins or supplements?
Starving self, binge eating, difficulty swallowing?
9.
Has child experienced any recent weight gain or loss?
Are there concerns with child’s height or weight?
10.
Allergies to food or medicine-
Reaction?
11.
Unexplained Fever
12.
Eyes or Vision
Date of last exam:_______
Any concerns, glasses or contacts needed
13.
Reproductive System
-Male or Female
Any concerns related to periods (heavy, not having), pregnancies,
sexually active, use birth control
14.
Headaches, Stomachaches, or Other Pains
15.
Heart, Blood, Circulatory System
Irregular heart beat, dizziness, fatigue with activity, chest pain,
tingling/numbness in extremities, treatment for any blood disorder
(anemia), blood transfusions
Hypertension
(High Blood Pressure)
Heart Disease
(Diagnosis of Heart Condition)
16.
Infectious Disease
(MRSA, hepatitis, meningitis, rubella, small
pox, whooping cough, mumps, chicken pox, pneumonia, etc)
Hepatitis C
HIV/AIDS
17.
Immunizations-
Seasonal flu immunization? Date: _______
up to date on immunizations?
18.
Motor Skills, Coordination, or Mobility
Does child have OT or PT? Use assistive device? Any trouble walking,
sitting, or stiffness? Any difficulties with falls?
19.
Metabolic Syndrome
(A cluster of risk factors that together, may lead to heart disease. Also
known as Dysmetabolic Syndrome or Syndrome X)
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