Health Appraisal - Ward Preschool

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Dear Parent or Guardian: The following information is requested so that the school can work with the parent to meet the physical, intellectual and emotional needs of the child. Fill out the information requested in Section I. Section III may be certified by the transcription of information from the certificate of immunization. The remaining sections are to be completed by a doctor, nurse and dentist. (BE SURE TO BRING YOUR CHILD’S IMMUNIZATION RECORDS TO THE EXAMINATION.)

Personal

Child's Name*

Date of Birth*

Address*

Street Address City State ZIP Code

Parent / Guardian Name*

Home Telephone Number*

Parent / Guardian Address*

Street Address City State ZIP Code

Work Telephone Number*

Section I - Health History

Is your child having any of the problems listed below?

Allergies or Reactions (for example, food, medication or other)*

Yes
No
Resolved

Hay Fever, Asthma, or Wheezing*

Yes
No
Resolved

Eczema or Frequent Skin Rashes*

Yes
No
Resolved

Convulsions/Seizures*

Yes
No
Resolved

Heart Trouble*

Yes
No
Resolved

Diabetes*

Yes
No
Resolved

Frequent Colds, Sore Throats, Earaches (4 or more per year)*

Yes
No
Resolved

Trouble with Passing Urine or Bowel Movements*

Yes
No
Resolved

Shortness of Breath*

Yes
No
Resolved

Speech Problems*

Yes
No
Resolved

Menstrual Problems*

Yes
No
Resolved

Dental Problems*

Yes
No
Resolved

Date of last dental exam ("None" or "Unknown" is acceptable)*

Other Health Problems? (please describe)

Does your child take any medication(s) regularly?*

Yes
No

If yes, reason for medication*

If yes, list medications*

Birth History:

*History applicable to the health of your child we should know.

Are there any current or past diagnosis(es)?*

Yes
No

If yes, please describe*

Was the health history reviewed by a health professional?*

Yes
No

Parent / Guardian Signature*

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Digital Signature Acknowledgement*

By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.

This document requires a health examiner's signature / initials. After submission, please print this form and give to your health professional to review and sign. Then give completed document to Ward Preschool.