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Health Appraisal
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
*
MM slash DD slash YYYY
Address
*
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Parent / Guardian Name
*
Home Telephone Number
*
Parent / Guardian Address
*
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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
*
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.
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