Official Record Of

ATCAA Early Head Start/Head Start/State Preschool/General Child Care

Official Record of: ______DOB: ______

Head Start Health/Nutrition Face Sheet

1st. yr. / 2nd yr. / 3rd yr.
Immunizations / Follow-up □ Complete □ / Review Date: / Review Date:
Health History / Date:
Follow-up □ Complete □ / Review Date: / Review Date:
Medication/Allergy Forms
(place under this face sheet) / Yes □ No □ / Yes □ No □ / Yes □ No □
Health Agreement / Date: / Review Date: / Review Date:
Physical Exam
(30 days) / Date: / Review Date: / Review Date:
Vision Screening
(45 days) / Date:
Physical □ Head Start□
Referred □ Tx Done □ / Date:
Physical □ Head Start □
Referred □ Tx Done □ / Date:
Physical □ Head Start □
Referred □ Tx Done □
Hearing Screening
(45 days) / Date:
Physical □ Head Start □
Referred □ Tx Done □ / Date:
Physical □ Head Start □
Referred □ Tx Done □ / Date:
Physical □ Head Start □
Referred □ Tx Done □
Blood Pressure
(45 days)
Result: _____/_____ / Date:
Physical □ Head Start □
Referred □ Tx Done □ / Review Date: / Review Date:
Hemoglobin _____.___
or Hematocrit ______% (45 days) / Date:
Referred □ Tx Done □ / Review Date: / Review Date:
Lead screening Results
12 months and/or 24 months / Date:
Referred □ Tx Done □ / Review Date: / Review Date:
Smile Keepers Permission Slip
Child can have fluoride & varnish? / Date:
Yes □ No □ / Review Date:
Yes □ No □ / Review Date:
Yes □ No □
Fluoride (Health History Question)
Child takes fluoride at home? / Date:
Yes □ No/Referred □ / Review Date:
Yes □ No/Referred □ / Review Date:
Yes □ No/Referred □
Dental Screening
(90 days) / Date:
Referred □ Tx Done □ / Date:
Referred □ Tx Done □ / Date:
Referred □ Tx Done □
Nutrition Screening / Date: / Review Date: / Review Date:
Food Allergy/Special Diet Forms
(place under this face sheet) / Yes □ No □ / Yes □ No □ / Yes □ No □
CCFP Form (HS over-inc. or “state only”)
Enrollment documentation / Date:
Date: / Date:
Date: / Date:
Date:
First (Fall) Height & Weight
(45 days or 2wks. For late start)Result: / Date:
Ht: _____” Wt:_____lbs. / Date:
Ht: _____” Wt:_____lbs. / Date:
Ht: _____” Wt:_____lbs.
Second (Spring) Height & Weight
Result: / Date:
Ht: _____” Wt:_____lbs. / Date:
Ht: _____” Wt:_____lbs. / Date:
Ht: _____” Wt:_____lbs.
Nutrition Assessment
BMI Chart / Date:
Referred □ Tx Done □ / Date:
Referred □ Tx Done □ / Date:
Referred □ Tx Done □
TB Parent
TB Child (if indicated by Dr.) / Date TB Read:
Date TB Read: / Review Date:
Review Date: / Date TB Read:
Date TB Read:
Child Incident Report
“Owies” (see “owie” pocket) / Date: / Date: / Date:
Permission to apply sunscreen / Date: / Date: / Date:
Miscellaneous Information / Date:
Type: / Date:
Type: / Date:
Type:
CAR / Date:

Note: Please file items in order of the face sheet, with the most current on top.

Revised Jan 09 Operational Forms 1304.51 Face Sheet Health Nutrition