Early Head Start Child Health History Form
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1Head Start/Early Head Start Child Health History
Center ________________________________________
Child’s Name: __________________________________ M F DOB: ___________
Medical Home: Medi-Cal Private None/Referred to Central Office Other (please explain) _________________
Doctor’s Name: _______________________________ Phone: ______________________
Dentist’s Name: _______________________________ Phone: ______________________
Health History
Yes
No
If yes, please explain.
Did mother have any problems during pregnancy or delivery?
Was child born more than 3 weeks early?
Did the child have any problems at birth or during the first
month of life?
Condition (Circle “Yes” or “No”):
Has child ever had a serious accident (broken bones, head
injuries, fall, burns, poisoning)?
Was child hospitalized/ER visit? Y/N Was the situation resolved? Y/N
Describe allergy:
Does child have any allergies?
___________________________________________________________
a. When eating any foods?
_________________________________
b. When near animals, furs, insects, dust, etc?
Does the child require medication? Y/N
c. When taking any medications?
Will this medication be needed during school hours? Y/N
If yes, for what condition? _________________________
Is child being treated by a physician for any condition (asthma,
Does the child require medication? Y/N
seizures, anemia, diabetes, heart condition, etc...)?
Will this medication be needed during school hours? Y/N
Does your child experience any of the following:
a. Squinting
b. Crossed eyes
Has your child been prescribed glasses? Y/N
c. Seeing up-close
d. Seeing far away
Does your child:
a. Have trouble hearing
b. Have more than 3 ear infections in one year
c. Have tubes in his/her ears
Yes
No
Dental History
If yes, please explain.
Has your child seen a dentist?
Does your child have/experience:
a. Pain/bleeding from teeth and/or gums
b. Spots/cavities on teeth
c. Broken/cracked teeth
d. Foul odor from mouth
If “Yes”, what does your child drink from a bottle?
Does your child drink from a bottle?
Social Emotional Development
Yes
No
Please explain.
(leave blank if not applicable for age)
Did your child:
a. Sit by 8 months?
b. Walk by 14 months?
c. Use simple words by 18 months?
Does your child currently speak in sentences?
What words does your child use to describe:
X
X
a. _______________________________
a. Bowel movements
b. _______________________________
b. Urination
Does your child:
a. Often stumble or drop things?
b. Suck his/her thumb?
c. Bite his/her nails
X
X
How do you comfort your child when he/she is afraid or upset?
Is there anything else you would like us to know about your
child?
st
st
1
Year Parent Signature _________________________________ Date _________ 1
Year Staff Signature _________________________________ Date _________
nd
nd
2
Year Parent Signature _________________________________ Date _________ 2
Year Staff Signature _________________________________ Date _________
Follow-up information is located on Family Contact Form.
Revised
8/15
White – Child’s File
Canary – Parent
Distribution:
H/N Services 058
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