Education Service Center, Region 20
Head Start Program
Child Health History – Parent Interview
Child’s Name: _____Male _____Female DOB:
Staff Completing Form: Campus:
PR
Child’s Name:
(make a copy of physician notes, if needed)
Did the child have any birth problems or concerns that still affect them today?
Hospitalizations & Illnesses
In the last 6 months . . . / Yes / No / Explain “Yes” Answers
(make a copy of physician notes, if needed)
Has child been hospitalized or operated on?
Has child had a serious accident (broken bones, head injuries, falls, burns, poisoning)?
Has child had a serious illness?
Health Status / Yes / No / Explain “Yes” Answers
(make a copy of physician notes, if needed)
Has child ever had a convulsion or seizure? / If yes, when did it last happen? ______
Current Medication______
ACTION PLAN REQUIRED IF CONDITION NEEDS MONITORING
Is the child taking any medications? / If yes, a special consent form must be signed for the school nurse to administer any medication.
Is the child being treated at this time by a specialist for an ongoing condition? / Name(s) ______
Condition(s) ______
Has the child been diagnosed with any allergies? / If yes, type of allergy: ______
What foods? ______
PHYSICIAN DOCUMENTATION REQUIRED
What medicine? ______
What things? ______
How does the child react? ______
Does your child use an Epi-Pen? ______
ACTION PLAN REQUIRED
Does the child have a history of cardiac / heart disease that requires any modifications for this condition? / If yes, please describe: ______
______
If yes, make a copy of physician modification instructions.
Are there any conditions we haven’t talked about that gets in the way of the child’s everyday activities? / Describe how: ______
______
When? ______
Has your child been diagnosed with diabetes? / If yes, menu modifications from physician required.
Does your child currently have asthma? / If yes, an Asthma Action Plan is required.
Does child have bleeding that is difficult to control? / If yes, describe how to manage the bleeding.
HEAD START STAFF FOLLOW-UP COMMENTS:
Child’s Name:
Behavioral / Wellness History / Yes / No / If “Yes” is marked please specifyDo you have any concerns with your child’s sleep routine?
Does your child have difficulty with toileting independently?
Does your child’s teacher need any special instructions in caring for your child?
Does your child have difficulties socializing with other children his/her age?
Does your child have difficulties separating from parents/other adults?
Have there been any major changes in your child’s life in the last six months?
Are you or your family having any problems now that might affect your child?
Is there anything else you want to tell us about your child that will help us understand his/her needs, attitudes, or behavior?
Nutrition History / Yes / No / If “Yes” is marked please specify
Does your child take any vitamins?
Are there any foods your child cannot eat for:
Religious Beliefs (If yes, parent must provide written instructions on religious dietary practices)
Medical (If yes, parent must provide written physician’s instructions)
About how often does your child eat a food from each of the following groups on a daily basis? / Never / Once a day / 2+ times a day
a. Milk, cheese, yogurt
b. Meat, poultry, fish, eggs or dried beans/peas, peanut butter
c. Rice, grits, bread, cereal, tortillas
d. Vegetables
e. Fruit
f. Oil, butter, margarine, lard
g. Cakes, cookies, sodas, fruit drinks, candy
What type of milk does your child drink?
Circle NONE if the child is allergic to milk. / Circle all that apply: Whole Milk 2% Milk 1% Milk
None Skim Milk Soy Milk Almond Milk
Indicate the number of cups your child drinks per day of each of the beverages listed. / ______Milk ______Juice ______Soda ______Kool-Aid ______Water ______Sweet/Un-sweet Tea
How many times per week does your family eat fast food?
How much time does your child participate in physical activity per day?
How many hours per day of “screen time” does your child watch per day? (TV, computer, video games, cell phone, iPad, etc.)
What type of snacks does your child typically eat?
HEAD START STAFF FOLLOW-UP COMMENTS:
3 of 3
March 2017/CM