Child Health Assessment
Name of Child Birthdate
Check All That Apply:
Does your child have any known allergies or sensitivities to:
If yes, please list:
Illnesses or Medical Conditions:
Does your child have any of the following:
Behavioral or Emotional Problems
List any additional health information or special instructions you feel we need to be aware of:
List any regular medications your child takes:
Name of Child’s Medical Provider:
This form must be completed for each individual child enrolled and must be reviewed annually by the parent/guardian, and any changes noted.
This form is provided for technical assistance purposes only. Providers may use this form if they choose, but are not required to use this form.
Child Admission Form & Health Information DOH/BCCL 8/09
Reviewed and/or update: January 25, 2020
Parent / Guardian Signature
Leave this empty:
If you have questions about the contents of this document, you can email the document owner.
Document Name: Child Health Assessment
Agree & Sign