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PART I: CHILD’S HEALTH AND INDIVIDUAL NEEDS INFORMATION

To be completed by PARENT/GUARDIAN

CHILD’S NAME: _________________________

IMPORTANT

: COMPLETE PART I BEFORE THE HEALTH PRACTITIONER EXAMINES YOUR CHILD. TAKE THIS FORM WITH YOU TO

THE HEALTH PRACTITIONER. PLEASE CHECK CORRECT ANSWERS TO THE FOLLOWING QUESTIONS IN COLUMNS ON THE RIGHT.

Explanation, if needed, can be given in the space provided for “REMARKS”.

YES

Are you concerned about your child’s general health (eating, sleeping habits, teeth, skin, menstruation, weight,

_____

bowel/bladder, etc.)?

2. Does your child have any eye problems (difficulty seeing, crossed eyes, frequently reddened or watery eyes)?

_____

Date of last eye examination: _____/ _____/ _____

Doctor’s Name: ___________________________

Results: _____________________________________________________________________________________

Does your child wear glasses?

_____

Contact lenses?

_____

3. Does your child have any ear or hearing problems (frequent earaches, difficulty hearing, etc.)?

_____

Date of last hearing evaluation _____/ _____/ _____

Doctor’s Name: ___________________________

Results: _____________________________________________________________________________________

Does your child use a hearing aid?

_____

4. Does your child have any speech problems (difficulty having speech understood, stammering, delayed speech

_____

development, etc.)?

5. Does your child have any allergies? If YES, please state what kind of allergies:

_____

6. Does your child have any other specific illness, disability or other limiting condition? If YES, answer a, b and c:

_____

(a) Does this condition require any special health care in the child care facility?

_____

(b) Has your child received evaluation(s), which could help the child care provider or teacher in meeting his/her

_____

health or educational needs?

_____

7. Do you have concerns about your child’s behavior or emotional well-being which the child care provider or teacher

_____

should know about?

8. Do you have concerns about your child’s social or developmental needs which the child care provider or teacher

_____

should know about?

REMARKS (Provide further explanation for all “YES” answers): ________________________________________________________________________

______________________________________________________________________________________________________________________________

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.

_______________________________________________

_____________________

Signature of Parent/Guardian

Date

OCC 1215 - Revised 6/08 - All previous editions are obsolete and replaces OCC 1215A, OCC 8506 and use of DHMH 896.

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Health Inventory Form - Child'S Personal Record For Child Care Facilities - Maryland State Department Of Education Page 2

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