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%%%%%%%%%%%%%%%%%%%%%%New%Hampshire%Early%Childhood%Health%Assessment%Record

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FOR$USE$FROM$BIRTH$THROUGH$GRADE$3

To$Parent$or$Guardian:$$In$order$to$provide$the$best$experience$for$your$child,$early$childhood$providers$and$school$staff

must$understand$your$child's$health$needs.$ T his$form$requests$information$from$you$(Part$I)$which$also$will$be

helpful$to$the$primary$health$care$provider$when$he$or$she$completes$the$health$evaluation$(Part$II).

Part%I:%

%FAMILY%INFORMATION%AND%HEALTH%HISTORY%(to%be%completed%by%parent%or%guardian)

Important:$Complete$this$page$BEFORE$you$give$this$form$to$your$child's$primary$care$provider.

Please$print

!Name!of!Child/Student

!Birth!Date

!Sex

!Primary!Care!Provider

!(Last,!First,!Middle)

!Address!

!Town!and!ZIP!Code

(Street)

!Parent/Guardian!

!Home!Phone!Number

!Work/Cell!Phone!Number

(Last,!First,!Middle)

*If$your$child$does$not$

$have$health$insurance,$

Is!your!child!currently!enrolled!in!WIC?!!!!!!!!!!!!

Yes!!!!/!!!!No

!!!!!!!!!!!!!!!!!!!!Does!your!child!have!health!insurance?

! Y es!!!!/!!!!No*

call$1–877–464–2447

(Children's$Medicaid$Unit)

Please!check!"Yes"!or!"No"!next!to!each!question!below.!Use!this!checklist!to!talk!to!your!child's!primary!care!provider!about!your!answers.

Yes!!!No

□ □

Do!you!have!any!questions!or!concerns!about!your!child's!health,!development,!or!behavior?

If$"Yes,"$be$sure$to$discuss$these$with$your$child's$primary$care$provider.$You$may$also$contact$NH$Watch$Me$Grow$at$your$community's$family$

resource$center$(for$children$<$6$years)$or$your$school$district$(children$3$and$older)$for$information$about$free$screenings.

□ □

Do!you!have!any!concerns!about!your!child's!eating!or!sleeping!habits?

□ □

Has!your!child!had!a!dental!exam!in!the!past!6!months?

□ □

Does!your!child!have!any!ongoing!health!problems!(such!as!asthma,!diabetes,!or!seizure!disorder)?

□ □

Does!your!child!have!any!allergies!(to!food,!medication,!insects,!latex,!etc.)?

□ □

Does!your!child!require!a!special!diet!while!in!school!or!other!early!childhood!program?

□ □

Does!your!child!take!any!medications!(daily!or!occasionally)?

□ □

Does!your!child!have!any!difficulty!with!his/her!vision,!hearing,!or!speech?

□ □

In!the!past!12!months,!has!your!child!experienced!any!difficulty!with!wheezing!or!coughing?

□ □

In!the!past!12!months,!have!you!been!concerned!about!a!change!in!your!child's!weight?

□ □

In!the!past!12!months,!have!you!noticed!any!change!in!your!child's!appetite!or!thirst?

□ □

In!the!past!12!months,!have!you!noticed!that!your!child!is!urinating!more!frequently?

□ □

Has!your!child!ever!been!hospitalized!or!had!any!operations,!procedures,!or!special!tests?

Explain!any!"yes"!answers!here.!Give!approximate!dates!for!any!hospitalizations,!operations,!or!serious!illnesses:

PERMISSION%TO%EXCHANGE%INFORMATION

Name!of!Parent/Guardian

,!authorize!and!request!my!child's!primary!care!provider

!!!to!exchange!information!about!my!child's!health!and!development!as!pertains!to!this!form!with!the!program/school!listed!below.

!!!The!information!may!be!provided!by!phone,!fax,!mail,!or!in!person.!I!understand!that!the!disclosed!information!will!be!considered!

!!!confidential!and!will!be!used!only!for!the!health!and!educational!benefit!of!my!child!and!family.!Except!as!needed!to!comply!with!

!!!federal!and!state!regulations,!it!will!not!be!re^disclosed!to!any!other!person,!school,!or!agency!without!my!consent.!I!understand

!!!!that!this!form!will!expire!in!one!year!unless!I!choose!to!cancel!my!permission!in!writing!before!that!time.

Name!of!Program/School!Requesting!Information

Program/School!Mailing!Address

Signature!of!Parent/Guardian

Date

Program/School!Telephone!Number

Fax!Number

Signature!of!Witness

Date

Endorsed!by!the!NH!Department!of!Health!and

Human!Services;!the!NH!Department!of!Education;

May!2012!

NH!Women,!Infants!&!Children!Nutrition!Program;

Head!Start;!and!the!NH!Pediatric!Society

New Hampshire Early Childhood Health Assessment Record - Nh Department Of Health And Human Services

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