School-Age Child Health Form/Parent Statement of Health

HCCI July 2016 1

Parent/Guardian please complete pages 1 and 2.

Child’s name

Child’s birthdate Name of school Grade ____ School Telephone #

Parent/Guardian name #1

Parent/Guardian name #2

Child home address #1

Telephone # 1

Child home address #2

Telephone # 2

Where parent/guardian #1 works

Work address Telephone #

Work #

Cellular #

Home email

Work email

Where parent/guardian #2 works

Work address Telephone #

Work #

Cellular #

Home email

Work email

In the event of an emergency, the child care provider is authorized to obtain EMERGENCY MEDICAL or DENTAL CARE even if the child care facility is unable to immediately make contact with the parent/guardian. YES NO During an emergency the child care provider is authorized to contact the following person when parent or guardian cannot be reached. Parent/Guardian Signature: ______________________________________________ Date _______________ Alternate emergency contact person’s name:_______________________________ Phone # ___________________ Relationship to child:___________________________ Cellular # ___________________

Child’s Doctor’s name

Child does not have doctor

Doctor telephone #1 Hospital of choice Phone #_____________________

Doctor’s address After hours telephone # Does your child have health insurance? YES NO Company ______________ ID#

Child’s Dentist’s name

Child does not have dentist

Dentist telephone #1 Does your child have dental insur-ance? YES NO Company ______________ ID#

Dentist’s address After hours telephone # HELP us find a family doctor or dentist

HELP us find health or dental insurance

Other health care/mental health specialist name Type of specialty

Telephone #

Child

Nam

e: _

____________________________________________________________

School-Age Child Health Form/Parent Statement of Health

HCCI July 2016 2

Parent/Guardian complete this page Child name: ___________________________________

Please use an X in the box to statements that

apply to your child.

Date of child’s last physical exam: ___________ Date of last dental appointment: _____________

Growth

I am concerned about child's growth. Appetite

I am concerned about child's eating habits. Rest

My child needs to rest after school. Illness/Surgery/Injury

My child had a serious illness, surgery, or in-jury. Please describe:

Physical Activity - My child

Must restrict physical activity or needs special equipment to be active. Please describe: Play with friends - My child

Plays well in groups with other children. Will play only with one or two other children. Prefers to play alone. Fights with other children. I am concerned about my child's play activity

with other children. School and Learning - My child

Is doing well at school. Is having difficulty in some classes. Does not want to go to school. Frequently misses or is late for school. I am concerned about how my child is doing

in school. Please describe:

Allergy - My child has allergies (Medicine, food,

dust, mold, pollen, insects, animals, etc.). List allergies:

Special Needs Care Plan –My child has a

special needs care plan (IEP, Asthma Action Plan,

Food Allergy Action Plan, etc.). Please discuss with your health care provider.

Body Health - My child has problems with

Skin, hair, fingernails or toenails.

Describe skin marks, birthmarks, or scars. Show us where these skin marks are located using the drawing below.

Eyes/vision, glasses or contact lenses Ears/hearing, hearing assistive aides or device, earache, tubes in ears

Nose problems, nosebleeds Mouth, teeth, gums, tongue, sores in mouth or on lips, breaths through mouth

Frequent sore throats or tonsillitis Breathing problems, asthma, cough Heart problems or heart murmur Stomach aches or upset stomach Trouble using toilet or wetting accidents Hard stools, constipation, diarrhea, watery stools Bones, muscles, movement, pain when moving Mobility, child uses assistive equipment Nervous system, headaches, seizures, or nerv-ous habits (like twitches or tics)

Females – difficult monthly periods Other special needs. Please describe:

Medication1 - My child takes medication. Medication Name Time Given Reason for giving medication

Child has Epipen, inhaler, or other emergency medication.

Yes No

Parent Signature: Date: (required)

1 Parents: Please review the child care program’s policies about the use of medication at child care.

School-Age Child Health Form/Parent Statement of Health

HCCI July 2016 3

HEALTH PROFESSIONAL COMPLETE PAGE

Date of Exam: ___________________

Height: ___________ Weight: ____________

Body Mass Index: __________,

There are weight concerns

Referral made to ______________________________________

Blood Pressure: _________

Laboratory Screening:

Blood Lead Level: Date_______ venous capillary (for

child under age 6 yr.) Results ___________ Hgb. / Hct: _______________

Urinalysis: _______________

TB testing (high risk child only) ______________

Sensory Screening

Vision Acuity: Right eye ________ Left eye _________

Hearing: Right ear ________ Left ear _________

Tympanometry: Right ear ________ Left ear _________

Exam Results (N = normal limits) otherwise describe

Skin:

HEENT:

Teeth/Oral health:

Date of Dentist Exam: __________ or none to date.

Dental Referral Made Today Yes No

Heart:

Lungs:

Stomach/Abdomen:

Genitalia:

Extremities, Joints, Muscles, Spine:

Neurological:

Psychosocial/Behavioral Assessment (Depression

screening starting at age 11)

Allergies

Environmental

Medication

Food

Insects

Other

:

Child Name: __________________________________ Date of Birth: ______________ Age: ________

Immunization: Please attach: Iowa Department of Public Health

Certificate of Immunization Iowa Department of Public Health

Certificate of Immunization Exemption Medical Iowa Department of Public Health

Certificate of Immunization Exemption Religious

Health provider authorizes the child to receive the following medications while at child care or school

(Including over-the-counter and prescribed) Medication Name Dosage

Fever/Pain reliever:

Sunscreen:

Cough medication:

Other - list all

Other Medication should be listed with written in-structions for use in child care. Medication forms available at www.idph.iowa.gov/hcci/products Referrals made:

Referred to hawk-i today 1-800-257-8563

Other: ______________________________

Health Provider Statement: The child may fully participate with NO health-

related restrictions.

The child has the following health-related re-strictions to participation: (please specify)

The child has a special needs care plan Type of plan ____________________________ (please attach)

Health Care Provider Comments: Signature __________________________________

Provider Type (circle) MD DO PA ARNP

Address: May use stamp Telephone:

The American Academy of Pediatrics has recommendations for frequency of childhood preventative pediatric health care (Bright Futures 2015) https://www.aap.org/en-us/Documents/periodicity_schedule.pdf

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AN

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IPA

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NC

E

1.

If a

child

com

es u

nder

car

e fo

r th

e fir

st ti

me

at a

ny p

oint

on

the

sche

dule

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if an

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ms

are

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acco

mpl

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sugg

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e, th

e sc

hedu

le

shou

ld b

e br

ough

t up

to d

ate

at th

e ea

rlies

t pos

sibl

e tim

e.

2.

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rena

tal v

isit

is r

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ded

for

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nts

who

are

at h

igh

risk,

for

first

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e pa

rent

s, a

nd fo

r th

ose

who

req

uest

a c

onfe

renc

e. T

he p

rena

tal v

isit

shou

ld in

clud

e an

ticip

ator

y gu

idan

ce, p

ertin

ent m

edic

al h

isto

ry, a

nd a

dis

cuss

ion

of b

enef

its o

f br

east

feed

ing

and

plan

ned

me

thod

of f

eedi

ng, p

er th

e 20

09 A

AP

sta

tem

ent “

The

Pre

nata

l Vis

it” (

http

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diat

rics.

aapp

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rg/c

onte

nt/1

24/4

/122

7.fu

ll).

3.

Eve

ry in

fant

sho

uld

have

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valu

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n af

ter

birt

h, a

nd b

reas

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ing

shou

ld b

e en

cour

aged

(an

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stru

ctio

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ppor

t sho

uld

be o

ffere

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4.

Eve

ry in

fant

sho

uld

have

an

eval

uatio

n w

ithin

3 to

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ays

of b

irth

and

with

in 4

8 to

72

hour

s af

ter

disc

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e fr

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e ho

spita

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incl

ude

eval

uatio

n fo

r fe

edin

g an

d ja

undi

ce. B

reas

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ing

infa

nts

shou

ld r

ecei

ve fo

rmal

bre

astfe

edin

g ev

alua

tion,

and

thei

r m

othe

rs s

houl

d re

ceiv

e en

cour

agem

ent a

nd

inst

ruct

ion,

as

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d in

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2012

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born

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disc

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tem

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New

born

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atio

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lood

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ildre

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fic r

isk

cond

ition

s sh

ould

be

perf

orm

ed a

t vis

its b

efor

e ag

e 3

yea

rs.

7.

A v

isua

l acu

ity s

cree

n is

rec

omm

ende

d at

age

s 4

and

5 ye

ars,

as

wel

l as

in c

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e 3

year

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nstr

umen

t bas

ed s

cree

ning

may

be

used

to

asse

ss r

isk

at a

ges

12 a

nd 2

4 m

onth

s, in

add

ition

to th

e w

ell v

isits

at 3

thro

ugh

5 ye

ars

of a

ge.

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201

6 A

AP

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tem

ent,

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ual S

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m A

sses

smen

t in

Infa

nts,

Chi

ldre

n, a

nd Y

oung

Adu

lts b

y P

edia

tric

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” (h

ttp://

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tent

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roce

dure

s fo

r E

valu

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n of

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Vis

ual S

yste

m b

y P

edia

tric

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” (h

ttp://

pedi

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licat

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tent

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8.

A

ll ne

wbo

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shou

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ed, p

er th

e A

AP

sta

tem

ent “

Yea

r 20

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ositi

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tate

men

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ples

and

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r E

arly

Hea

ring

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ectio

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d In

terv

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n P

rogr

ams”

(ht

tp://

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ll).

9.

See

200

6 A

AP

sta

tem

ent “

Iden

tifyi

ng In

fant

s an

d Y

oung

Chi

ldre

n W

ith D

evel

opm

enta

l Dis

orde

rs in

the

Med

ical

Hom

e: A

n A

lgor

ithm

for

Dev

elop

men

tal

Sur

veill

ance

and

Scr

eeni

ng”

(http

://pe

diat

rics.

aapp

ublic

atio

ns.o

rg/c

onte

nt/1

18/1

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.full)

. 10

. S

cree

ning

sho

uld

occu

r pe

r th

e 20

07 A

AP

sta

tem

ent

“Ide

ntifi

catio

n an

d E

valu

atio

n of

Ch

ildre

n w

ith A

utis

m S

pect

rum

Dis

orde

rs”

(http

://pe

diat

rics.

aapp

ublic

atio

ns.o

rg/c

onte

nt/1

20/5

/118

3.fu

ll).

11.

A r

ecom

men

ded

scre

enin

g to

ol is

ava

ilabl

e at

http

://w

ww

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12

. R

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men

ded

scre

enin

g us

ing

the

Pat

ient

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uest

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HQ

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ther

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tp://

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. 13

. A

t eac

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sit,

age-

appr

opria

te p

hysi

cal e

xam

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ssen

tial,

with

infa

nt to

tally

unc

loth

ed a

nd o

lder

chi

ldre

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and

suita

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drap

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ee

2011

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tate

men

t “U

se o

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pero

nes

Dur

ing

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sica

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atio

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Ped

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atie

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(http

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rics.

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ublic

atio

ns.o

rg/c

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nt/1

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. T

hese

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poin

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Her

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and

Chi

ldre

n, a

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new

born

scr

eeni

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ws/

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http

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ablis

h th

e cr

iteria

for

and

cove

rage

of n

ewbo

rn s

cree

ning

pro

cedu

res

and

prog

ram

s.

Fol

low

-up

mus

t be

prov

ided

, as

appr

opria

te, b

y th

e pe

diat

ricia

n.

16.

Scr

eeni

ng fo

r cr

itica

l con

geni

tal h

eart

dis

ease

usi

ng p

ulse

oxi

met

ry s

houl

d be

per

form

ed in

new

born

s, a

fter

24 h

ours

of a

ge, b

efor

e di

scha

rge

from

th

e ho

spita

l, pe

r th

e 20

11 A

AP

sta

tem

ent

“End

orse

men

t of H

ealth

and

Hum

an S

ervi

ces

Rec

omm

enda

tion

for

Pul

se O

xim

etry

Scr

eeni

ng

for

Crit

ical

C

onge

nita

l Hea

rt D

isea

se”

(http

://pe

diat

rics.

aapp

ublic

atio

ns.o

rg/c

onte

nt/1

29/1

/190

.full)

. 17

. S

ched

ules

, per

the

AA

P C

omm

ittee

on

Infe

ctio

us D

isea

ses,

are

ava

ilabl

e at

: ht

tp://

aapr

edbo

ok.a

appu

blic

atio

ns.o

rg/s

ite/r

esou

rces

/izsc

hedu

les.

xhtm

l. E

very

vis

it sh

ould

be

an o

ppor

tuni

ty to

upd

ate

and

com

plet

e a

child

’s im

mun

izat

ions

. 18

. S

ee 2

010

AA

P s

tate

men

t “D

iagn

osis

and

Pre

vent

ion

of Ir

on D

efic

ienc

y an

d Ir

on D

efic

ienc

y A

nem

ia in

Infa

nts

and

You

ng C

hild

ren

(0-3

Yea

rs o

f Age

)”

(http

://pe

diat

rics.

aapp

ublic

atio

ns.o

rg/c

onte

nt/1

26/5

/104

0.fu

ll).

19.

For

chi

ldre

n at

ris

k of

lead

exp

osur

e, s

ee th

e 20

12 C

DC

Adv

isor

y C

omm

ittee

on

Chi

ldho

od L

ead

Poi

soni

ng P

reve

ntio

n st

atem

ent

“Low

Lev

el L

ead

Exp

osur

e H

arm

s C

hild

ren:

A R

enew

ed C

all f

or P

rimar

y P

reve

ntio

n” (

http

://w

ww

.cdc

.gov

/nce

h/le

ad/A

CC

LPP

/Fin

al_D

ocum

ent_

0307

12.p

df).

20

. P

erfo

rm r

isk

asse

ssm

ents

or

scre

enin

gs a

s ap

prop

riate

, bas

ed o

n un

iver

sal s

cree

ning

req

uire

men

ts fo

r pa

tient

s w

ith M

edic

aid

or

in h

igh

prev

alen

ce

area

s.

21.

Tub

ercu

losi

s te

stin

g pe

r re

com

men

datio

ns o

f the

Com

mitt

ee o

n In

fect

ious

Dis

ease

s, p

ublis

hed

in th

e cu

rren

t edi

tion

of A

AP

Red

Boo

k:

Rep

ort o

f the

Com

mitt

ee o

n In

fect

ious

Dis

ease

s. T

estin

g sh

ould

be

perf

orm

ed o

n re

cogn

ition

of h

igh

-ris

k fa

ctor

s.

22.

See

AA

P-e

ndor

sed

2011

gui

delin

es fr

om th

e N

atio

nal H

eart

Blo

od a

nd L

ung

Inst

itute

, “I

nteg

rate

d G

uide

lines

for

Car

diov

ascu

lar

Hea

lth a

nd

Ris

k R

educ

tion

in C

hild

ren

and

Ado

lesc

ents

” (h

ttp://

ww

w.n

hlbi

.nih

.gov

/gui

delin

es/c

vd_p

ed/in

dex.

htm

).

23.

Ado

lesc

ents

sho

uld

be s

cree

ned

for

sexu

ally

tra

nsm

itted

infe

ctio

ns (

ST

Is)

per

reco

mm

enda

tions

in th

e cu

rren

t edi

tion

of th

e A

AP

Red

Boo

k:

Rep

ort o

f the

Com

mitt

ee o

n In

fect

ious

Dis

ease

s. A

dditi

onal

ly, a

ll ad

oles

cent

s sh

ould

be

scre

ened

for

HIV

acc

ordi

ng to

the

AA

P s

tate

men

t (h

ttp://

pedi

atric

s.aa

ppub

licat

ions

.org

/con

tent

/128

/5/1

023.

full)

onc

e be

twee

n th

e ag

es o

f 16

and

18, m

akin

g ev

ery

effo

rt to

pre

serv

e co

nfid

entia

lity

of th

e ad

oles

cent

. Tho

se a

t inc

reas

ed r

isk

of H

IV in

fect

ion,

incl

udin

g th

ose

who

are

sex

ually

act

ive,

par

ticip

ate

in in

ject

ion

drug

us

e, o

r ar

e be

ing

test

ed fo

r ot

her

ST

Is, s

houl

d be

test

ed fo

r H

IV a

nd r

eass

esse

d an

nual

ly.

24.

See

US

PS

TF

rec

omm

enda

tions

(ht

tp://

ww

w.u

spre

vent

ives

ervi

cest

askf

orce

.org

/usp

stf/u

spsc

erv.

htm

). In

dica

tions

for

pelv

ic e

xam

inat

ions

prio

r to

age

21

are

note

d in

the

2010

AA

P s

tate

men

t “G

ynec

olog

ic E

xam

inat

ion

for

Ado

lesc

ents

in th

e P

edia

tric

Offi

ce S

ettin

g”

(http

://pe

diat

rics.

aapp

ublic

atio

ns.o

rg/c

onte

nt/1

26/3

/583

.full)

.

25.

Ass

ess

if th

e ch

ild h

as a

den

tal h

ome.

If n

o de

ntal

hom

e is

iden

tifie

d, p

erfo

rm a

ris

k as

sess

men

t

(http

://w

ww

2.aa

p.or

g/or

alhe

alth

/doc

s/R

iskA

sses

smen

tToo

l.pdf

) an

d re

fer

to a

den

tal h

ome.

If p

rimar

y w

ater

sou

rce

is d

efic

ient

in fl

uorid

e,

cons

ider

ora

l flu

orid

e su

pple

men

tatio

n. R

ecom

men

d br

ushi

ng w

ith fl

uorid

e to

othp

aste

in th

e pr

oper

dos

age

for

age.

See

200

9 A

AP

sta

tem

ent

“Ora

l Hea

lth R

isk

Ass

essm

ent T

imin

g an

d E

stab

lishm

ent o

f the

Den

tal H

ome”

(ht

tp://

pedi

atric

s.aa

ppub

licat

ions

.org

/con

tent

/111

/5/1

113.

full)

,

2014

clin

ical

rep

ort “

Flu

orid

e U

se in

Car

ies

Pre

vent

ion

in th

e P

rimar

y C

are

Set

ting”

(ht

tp://

pedi

atric

s.aa

ppub

licat

ions

.org

/con

tent

/134

/3/6

26),

and

2014

AA

P s

tate

men

t “M

aint

aini

ng a

nd Im

prov

ing

the

Ora

l Hea

lth o

f You

ng C

hild

ren

(http

://pe

diat

rics.

aapp

ublic

atio

ns.o

rg/c

onte

nt/1

34/6

/122

4.fu

ll).”

26.

See

US

PS

TF

rec

omm

enda

tions

(ht

tp://

ww

w.u

spre

vent

ives

ervi

cest

askf

orce

.org

/usp

stf/u

spsd

nch.

htm

). O

nce

teet

h ar

e pr

esen

t, flu

orid

e va

rnis

h m

ay b

e ap

plie

d to

all

child

ren

ever

y 3-

6 m

onth

s in

the

prim

ary

care

or

dent

al o

ffice

. Ind

icat

ions

for

fluor

ide

use

are

note

d in

the

2014

A

AP

clin

ical

rep

ort “

Flu

orid

e U

se in

Car

ies

Pre

vent

ion

in th

e P

rimar

y C

are

Set

ting”

(ht

tp://

pedi

atric

s.aa

ppub

licat

ions

.org

/con

tent

/134

/3/6

26).

KE

Y

= t

o b

e p

erf

orm

ed

= r

isk a

sse

ssm

en

t to

be p

erf

orm

ed

wit

h a

pp

rop

riate

acti

on

to

fo

llo

w, if

po

sit

ive

= r

an

ge d

uri

ng

wh

ich

a s

erv

ice

ma

y b

e p

rovid

ed