Depot Daycare

Child Health Assessment

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:




No Yes


No Yes


Visual Impairment


Developmental Delays


Physical Impairment

Heart Problems

Behavioral or Emotional Problems

Hearing Impairment



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: February 16, 2024

Parent / Guardian Signature   

Leave this empty:

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Signature Certificate
Document name: Child Health Assessment
lock iconUnique Document ID: a8aaf2bf0701c84d81dbfb29bc7a4fb1e7083772
Timestamp Audit
March 29, 2018 3:32 pm MSTChild Health Assessment Uploaded by Ty Singleton - IP