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Pre School Health Assessment Form

This document contains a health assessment form for Christ's Little Acorns Preschool for the 2017-2018 year. The form collects personal information about the child such as name, birthdate, health problems, and illnesses or developmental issues. Parents or guardians are asked to provide personal data and check off any relevant health issues. The form also contains a health assessment section to be completed by a healthcare provider. The provider will assess immunizations, exemptions, the date of the assessment, and any other important health conditions. They will also note if any illnesses or conditions could affect the child's school performance. Space is included to list allergies and medications.

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Victor Barbosa
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64 views1 page

Pre School Health Assessment Form

This document contains a health assessment form for Christ's Little Acorns Preschool for the 2017-2018 year. The form collects personal information about the child such as name, birthdate, health problems, and illnesses or developmental issues. Parents or guardians are asked to provide personal data and check off any relevant health issues. The form also contains a health assessment section to be completed by a healthcare provider. The provider will assess immunizations, exemptions, the date of the assessment, and any other important health conditions. They will also note if any illnesses or conditions could affect the child's school performance. Space is included to list allergies and medications.

Uploaded by

Victor Barbosa
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Christ’s Little Acorns Preschool

Health Assessment Form 2017-2018


1300 North University Parkway, High Point, NC 27262
Phone: 336-889-6169 • Fax: 336-889-6528

Personal Data (TO BE COMPLETED BY PARENT OR GUARDIAN)
Child’s Name: ______________________ ______________________ ______________________
Last First Middle
Birthdate: ______/______/________ Age: ______ Sex: □ Male □ Female
Month Day Year
Please list any health problems that might affect your child’s performance in school: _________________
____________________________________________________________________________________

Illnesses or Developmental Problems (Please check any of the following that the child has):
□ Asthma □ Convulsions/Seizures □ Ear Infections □ Skin Problems
□ Bleeding Problems □ Cystic Fibrosis □ Heart Problems □ Speech Problems
□ Bone/Muscle Problems □ Cerebral Palsy □ Hearing Problems □ Stomach Aches
□ Bowel Problems □ Dental Problems □ Meningitis □ Urinary/Bladder
□ Cancer/Leukemia □ Diabetes □ Sickle Cell Anemia □ Other_________
□ Attention/Learning □ Emotional/Behavioral □ Vision Problems □ NONE


Health Assessment (TO BE COMPLETED BY HEALTHCARE PROVIDER)
The health assessment must be conducted by a physician licensed to practice medicine, a physician’s assistant as defined in General Statute 90-18, a certified nurse
practitioner, or a public health nurse meeting the State standards for Health Check Services

Immunizations Exemptions
*Attach a copy of the child’s current immunization record. NC State Immunization Law require that a statement
must be on file at school in student’s permanent
record. (www.NVIC.org)
*Attach a copy of your exemption form
Date of Assessment: _______/_______/_______
Please provide additional information about illnesses or developmental problems. Also, provide information about any other
important health conditions. ____________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
In your opinion, will any of the above illnesses or conditions affect the child’s performance in school? If so, specify:________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________

List any allergies that the child has (e.g. food, insect stings, medicine, etc.):______________________________________
What type of allergic reaction occurs?_____________________________________________________________
Is medication required? □ No □ Yes If yes, medication and dosage: ___________________________________
Does this child take medication on a regular basis (other than above)? □ No □ Yes
If yes, list medication, purpose of medication, dose and possible side effects: _____________________________

Signature of Health Care Provider ________________________________ Date ___________________


Address: _______________________________________ Phone: ___________________________

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