Health Inventory - Enrollment Bright Horizons Page 2
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4PART I - HEALTH ASSESSMENT
To be completed by parent or guardian
Child’s Name:
Birth date:
Sex
Last
First
Middle
Mo / Day / Yr
M
F
Address:
Number
Street
Apt#
City
State
Zip
Parent/Guardian Name(s)
Relationship
Phone Number(s)
W:
C:
H:
W:
C:
H:
Your Child’s Routine Medical Care Provider
Your Child’s Routine Dental Care Provider
Last Time Child Seen for
Physical Exam:
Name:
Name:
Dental Care:
Address:
Address:
Any Specialist :
Phone #
Phone
ASSESSMENT OF CHILD’S HEALTH - To the best of your knowledge has your child had any problem with the following? Check Yes or No and
provide a comment for any YES answer.
Yes
No
Comments (required for any Yes answer)
Allergies (Food, Insects, Drugs, Latex, etc.)
Allergies (Seasonal)
Asthma or Breathing
Behavioral or Emotional
Birth Defect(s)
Bladder
Bleeding
Bowels
Cerebral Palsy
Coughing
Communication
Developmental Delay
Diabetes
Ears or Deafness
Eyes or Vision
Feeding
Head Injury
Heart
Hospitalization (When, Where)
Lead Poisoning/Exposure
Life Threatening Allergic Reactions
Limits on Physical Activity
Meningitis
Mobility-Assistive Devices if any
Prematurity
Seizures
Sickle Cell Disease
Speech/Language
Surgery
Other
Does your child take medication (prescription or non-prescription) at any time? and/or for ongoing health condition?
No
Yes, name(s) of medication(s):
Does your child receive any special treatments? (Nebulizer, EPI Pen, Insulin, Counseling etc.)
No
Yes, type of treatment:
Does your child require any special procedures? (Urinary Catheterization, G-Tube feeding, Transfer, etc.)
No
Yes, what procedure(s):
I GIVE MY PERMISSION FOR THE HEALTH PRACTITIONER TO COMPLETE PART II OF THIS FORM. I UNDERSTAND IT IS
FOR CONFIDENTIAL USE IN MEETING MY CHILD’S HEALTH NEEDS IN CHILD CARE.
I ATTEST THAT INFORMATION PROVIDED ON THIS FORM IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE
AND BELIEF.
__________________________________________________________________________
________________________________________
Signature of Parent/Guardian
Date
OCC 1215 - Revised August 2015 - All previous editions are obsolete.
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