Child Health Appraisal - Delaware Department Of Services For Children, Youth And Their Families
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1STATE OF DELAWARE
DEPARTMENT OF SERVICES FOR CHILDREN,
NAME_____________________
YOUTH AND THEIR FAMILIES
Family Child Care
OFFICE OF CHILD CARE LICENSING
Large Family Child Care Home
Day Care Center
CHILD HEALTH APPRAISAL
BIRTHDATE_____________
SECTION A: TO BE COMPLETED BY PARENT BEFORE PHYSICAL EXAMINATION
CHECK IF CHILD HAS PROBLEMS WITH ANY OF THE FOLLOWING: GIVE ADDITIONAL COMMENTS BELOW
Allergies
Frequent Colds
Fainting
Physical Handicap
(food, medicine, bee sting etc.)
Hearing Difficulty
Speech Difficulty
Behavior Problem
Constipation/Diarrhea
Seizures
Vision Difficulty
Asthma
Other______________________________________________________________________________________________________
Comments:_________________________________________________________________________________________________
ADDITIONAL INFORMATION ABOUT YOUR CHILD (include serious illness, accidents, operations, medications, etc. with dates):
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Parent/Guardian’s Signature__________________________________________________Date______________________________
SECTION B: TO BE COMPLETED BY EXAMINING PHYSICIAN/PEDIATRIC NURSE PRACTITIONER
CODE:
X - Within Normal Limits
O - See Remarks Below
_____ Scalp, Skin
_____ Heart
_____ Vision
_____ Ear, Nose
_____ Lungs
_____ Hearing
_____ Throat
_____ Abdomen
_____ Blood Pressure
_____ Eyes
_____ Genitalia
_____ Teeth
_____ Extremities
_____ Neck, Glands
_____ Nervous System
_____ Height
_____ Weight
REMARKS AND RECOMMENDATIONS: _____________________________________________________________________
__________________________________________________________________________________________________________
IS CHILD PROGRESSING NORMALLY FOR AGE GROUP? ______________________________________________________
DTP/Hib 1
DTP/Hib 2
DTP/Hib 3
DTP/ Hib 4
DTaP/Hib 4
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DTP/DTaP 1 / DT
DTP/DTaP 2 / DT
DTP/DTaP 3 / DT
DTP/DTaP 4 / DT
DTP/DTaP 5 / DT
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Td 1
Td 2
Td 3
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OPV/IPV 1
OPV/IPV 2
OPV/IPV 3
OPV/IPV 4
TB Screening 12 mo
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MMR 1
MMR 2
HepB 1
HepB 2
HepB 3
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Hib 1
Hib 2
Hib 3
Hib 4
Hep B/Hib 1
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Hep B/Hib 2
Hep B/Hib 3
Varicella 1
Varicella 2
Influenza 1
/
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Influenza 2
Pneumococcal
Pneumococcal
Pneumococcal
Pneumococcal
Polysaccharide1
Polysaccharide 2
Conjugate 1
Conjugate 2
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Pneumococcal
Pneumococcal
Hep A 1
Hep A 2
Lyme Vax 1
Conjugate 3
Conjugate 4
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Lyme Vax 2
Lyme Vax 3
Other:
Lead Screening 12 mo
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Examiner’s Signature_________________________________________
M.D.
P.N.P.
Date:_____________________________________
Printed Name:________________________________________________ Telephone:___________________________________________________
DOC.NO. 37-06-10-01-01-01
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