Form Ccl 358 - Kansas Health History For Children And Youth Attending School Age Programs - Department Of Health And Environment Page 2

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Circle any of the following conditions or difficulties that affect this child or youth.
Allergies
Frequent sore throats/ colds
Ear Infections or Aches
Heart or Lung Conditions
Skin Problems
Asthma
Headaches
Diabetes
Vision
Speech/Communication
Hearing
Emotion/Behavior
Other: Please describe.
If you circled any of the above conditions, please provide additional information that will help the staff members meet the
child’s or youth’s needs while attending the program. (Attach additional page, if needed.)
Provide additional information about your child or youth that might affect him/her while at the School Age Program
including any special needs, restrictions to activities, major changes at home or special instructions. (Attach additional
page, if needed.
Complete the following information about this child’s or youth’s immunization status.
Yes
No
Did this child or youth attend a public or accredited non-public school in Kansas, Missouri or Oklahoma
the previous year?
If yes, are this child’s or youth’s immunizations current?
If yes to both of these questions, you do NOT need to complete the immunization history below.
If no to either of the above questions, you must complete the immunization history below for this child or
youth or attach a copy of the child’s or youth’s immunization history.
Please give dates in the space below for ALL immunization series completed by this child or youth. Record MM/DD/YYYY.
1
2
3
4
5
DPT, DT*, TD (*DT only if child is allergic to DTP)
/ /
/ /
/ /
/ /
/ /
POLIO
/ /
/ /
/ /
/ /
MMR
/ /
/ /
Single
RUBEOLA (MEASLES)
/ /
/ /
Dose
Only
MUMPS
/ /
/ /
RUBELLA (GERMAN MEASLES)
/ /
/ /
HIB (Hemophilus Influ. B)
*RECOMMENDED
/ /
/ /
/ /
/ /
HBV (Hepatitis B Vaccine)
*RECOMMENDED
/ /
/ /
/ /
VAR (Varicella-Chicken Pox) *RECOMMENDED
/ /
Print the First and Last Name of the Person Completing this Health History form
Relationship to the
Date Completed
Child/Youth
What is that person’s relationship to
If the Health History form was completed by a person other than a Parent/Guardian,
who provided you with this information?
the child/youth?
I attest, under penalty of perjury, that to the best of my knowledge, the information provided on this form is true and correct.
Signature of person completing this form
Date Signed

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