Long Island Head Start Health Content Area Case File Review Checklist

Center: ______Family Advocate: ______

SCCC Student Name: ______Date: ______

Case #
1st Section - Left Side
Consent From A
Consent From B
Consent Form D
Health History
Nutrition History
Growth Charts
Referral for Nutrition
First Section - Right Side
Physical Form
Immunization Form
Health/Nutrition Alert Sheet
Medical Provider Form
Check off boxes on physical complete
Vision Screening
Hearing Screening
Lead
PPD
Blood Pressure
Hgb./Hct.
Referral for Health
Dental Exam Form
Dental Follow-up Form
2nd Section – Left Side
Individual Health Care Plan **
Medication Consent Forms
Medication Advisement Form
Nutrition Care Plan or Special Menu

Key:

1 / Form is in place & Complete / 6 / Form is missing parent/guardian signature
2 / Form is missing / 7 / Form is missing provider’s signature
3 / Form not applicable / 8 / Incomplete/Information missing
4 / Form expired / 9 /

Follow-up needed

5 / Form is missing Family Advocate signature / 10 / Immunizations in process

Comments: ______

** Please note – children with special health care plan should have a yellow dot on file