Beaufort Jasper EOC Head Start

Health History/Nutrition Assessment

What program option are you registering for?*

1) Medical History

How much did your child weigh at birth?* Lbs. oz.

Has anyone in your family ever had any serious illness or medical conditions? (i.e. heart disease, cancer, tuberculosis, asthma, mental illness, etc.) if Yes, please explain.
Were there any problems with your child immediately after birth? if Yes, please explain.
Is your child taking any medications every day? if Yes, please explain.
Will medication be needed at school? if Yes, please explain.
Has your child ever been prescribed a EPI-PEN? if Yes, please indicate allergy.
Are there any conditions requiring special attention at childcare setting/school? if Yes, please explain.
Is your child allergic to any of the following? (Please circle) Animals, perfume, trees, pollen, grass, flowers, dust, other?
Does anyone in the household smoke? (Where? i.e. at home?)
2) Has your child ever had the following illnesses?
Yes Yes
Ear/Nose/Throat Problems
Eye Problems
Urinary/Kidney Problems
Heart Disease
Muscle/Bone Problems
Scarlet Fever
Intestinal Problems
Respiratory Problems
Blood Pressure Problems
Rheumatic Fever
Bee Sting Allergy
None of the above

If you answered yes to any illness, please explain (i.e triggers, medications needed during program hours, how long ago, how often, etc.).

3) Has your child ever had the following? If so, please check the box, give date, and explain to the best of your knowledge.
Yes Date Comment
Serious Injuries
Other Health Problems/Illness
Allergies to Medication (i.e., penicillin)
4) Dental Information
Does your child have dental insurance? Name of Insurance.
Does your child have an ongoing source of continuous and accessible dental care/dentist?
Do you have a family dentist?
Dentist Name/Practice: Address: Phone Number:
Dose your child have dental problem now?
5) Nutrition Screening
Does your child eat a variety of foods, including fruits and vegetables?
Does your child drink from a baby bottle now?
Do you have any concerns about your child’s growth, nutrition or eating habits? (i.e. picky eater, constipation, diarrhea)? if Yes, please explain.
6) Food Substitution
Is your child restricted from foods due to religious, medical, or personal reasons? if Yes, please explain. (i.e. What food types, restrictions).
Does your child have any food allergies or intolerances? if Yes, please explain. What kind of reactions does your child have, when your child eats the food in the above questions? (please circle) Rash, Swelling, Diarrhea, Difficulty breathing, Life threatening,
Is your child on any special diet prescribed by doctor? if Yes, please explain.
7) Asthma
Has your child ever been diagnosed by a medical professional as having asthma? (If your answer is NO, please skip to #8)
a) Date of diagnosis:
b) How many episodes per year?
c) Is it seasonal? At what time of the year do the episodes most often occur?
d) Is it well controlled?
e) Asthma triggers?
2. Has your child experienced any of the following due to ASTHMA?
Treatment in the ER, number of times:
Hospitalizations; number of times:
3. Have you ever given your child any medications for asthma? If yes, please place a check on all that your child has used in the past two years.
Yes Yes Yes
Pedia Pred
Primatine Mist
4. Does your child use a Nebulizer or Inhaler? if Yes, how often.
8) Medical Coverage
1. Does your child have a family doctor? Does your child receive medical services through an ongoing source of continuous, accessible medical care? if Yes, please answer the following:
Doctor’s Name:
Phone Number:
2. Does your child have health insurance?
Name of Insurance:
I confirm that I have read and understand this form. *

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