Child Admission Agreement & Health Assessment Form Page 2
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1
2Child Health Assessment
Please Write Clearly. There must be a separate health assessment form for each sibling.
Name of Child ____________________________________________________________
Birth Date ______/______/___________
Check All That Apply:
Does your child have any known allergies or sensitivities to:
No
Yes If yes, please list:
Medications
________________________________________________________________________
Foods
________________________________________________________________________
Other
________________________________________________________________________
Illnesses or Medical Conditions:
Does your child have any of the following:
No
Yes
No
Yes
Asthma
Visual Impairment
Diabetes
Developmental Delays
Seizures
Physical Impairment
Heart Problems
Behavioral or Emotional Problems
Hearing Impairment
Other: ________________________________________________________
List any additional health information or special instructions you feel we need to be aware of:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
List any regular medications your child takes: ______________________________________________________________________
Name of Child’s Medical Provider: _______________________________________________________________________________
_______________________________________________________________
______/______/______
Parent / Guardian Signature
Date
This form must be completed for each individual child enrolled, and must be reviewed annually by the parent/guardian, and any
changes noted.
Reviewed and/or update: ______/______/______
Parent/Guardian Signature: _______________________________________
Reviewed and/or update: ______/______/______
Parent/Guardian Signature: _______________________________________
Reviewed and/or update: ______/______/______
Parent/Guardian Signature: _______________________________________
This form is provided for technical assistance purposes only. Providers may use this form if they choose, but are not required to use this form.
Child Admission Form & Health Assessment
DOH/CCL 12/12
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