History Of Immunizations Form, Form Ccl. 029a - Child Health Assessment (Page 2 of 2) in pdf

History Of Immunizations Form, Form Ccl. 029a - Child Health Assessment Page 2

CCL. 029a

Rev. 8/2013

Child Health Assessment

The Child Health Assessment form is to be completed and signed by a nurse approved by KDHE to perform Child Health

Assessments or a Licensed Physician. If a Physician Assistant (PA) completes the Child Health Assessment, the signature

of the Licensed Physician authorizing the PA is to be included at the bottom of this form.

A Child Health Assessment, recorded on a KDHE Form or other acceptable Forms mentioned below, is required for all

children including children of the provider or staff in Licensed Day Care Homes, Group Day Care Homes, Child Care

Centers and Preschools. A Kan-Be-Healthy Assessment Form is a KDHE Form and is acceptable, a Physician Health

Assessment Form is acceptable, and a School Health Assessment Form is acceptable for school-age children or youth.

The Health Assessment Form used should be attached to the KDHE Medical Record Form (CCL. 029).

Child’s Name_________________________________________

Date of Birth___________________

First

Last

Health history and medical information pertinent to routine child care and emergencies

Do you see this child for regular

(describe, if any):

health supervision:

 None

Yes

 No



Allergies to food or medicine (describe, if any):

 None

List current medications (if any):

 None

Length/Height: ______IN/CM

%ILE_______

Weight: _____LB/KB

%ILE_______

Physical Examination

If Normal

If Abnormal - Comments



Head/Ears/Eyes/Nose/Throat

Teeth

Cardio/Respiratory

Abdomen/GI

Genitalia/Breasts

Extremities/Joints/Back/Chest

Skin/Lymph Nodes

Neurologic & Developmental

Screening Tests

Screening Date

Note Here if Results are Pending or Abnormal

Lead

Anemia (HGB/HCT)

Urinalysis (UA)

Hearing

Vision

Health Problems or Special Needs, Recommended Treatment/Medications/Special Care (Attach additional sheets if necessary)

 None

Signature of Licensed Physician or Nurse approved for Child Health Assessments

Date

Print the Name of the Individual Signing Above

Phone Number

Address

City

Zip Code

History Of Immunizations Form, Form Ccl. 029a - Child Health Assessment Page 2

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