The Learning Barn Childcare Center Preschool Daycare Naugatuck, CT, 06770. Child

To Parent or Guardian: In order to provide the best experience, early childhood providers must understand your child’s health needs. This form requests information from you (Part I) which will be helpful to the health care provider when he or she completes the health evaluation (Part II). State law requires complete primary immunizations and a health assessment by a physician, an advanced practice registered nurse, a physician assistant, or a legally qualified practitioner of medicine, an advanced practice registered nurse or a physician assistant stationed at any military base prior to entering an early childhood program in Connecticut.

Gender

Male Female

Race/Ethnicity

American Indian/Alaskan Native Black, not of Hispanic origin White, not of Hispanic origin Hispanic/Latino Asian/Pacific Islander Other

Does your child have health insurance?

Yes No

Does your child have dental insurance?

Yes No

Does your child have HUSKY insurance?

Yes No

Part I — To be completed by parent/guardian

Please answer these health history questions about your child before the physical examination

Concern	Yes	No
Any health concerns
Allergies to food, bee stings, insects
Allergies to medication
Any other allergies
Any daily/ongoing medications
Any problems with vision
Uses contacts or glasses
Any hearing concerns
Frequent ear infections
Any speech issues
Any problems with teeth
Has your child had a dental examination in the last 6 months
Very high or low activity level
Weight concerns
Problems breathing or coughing
Asthma treatment
Seizure
Diabetes
Any heart problems
Emergency room visits
Any major illness or injury
Any operations/surgeries
Lead concerns/poisoning
Sleeping concerns
High blood pressure
Eating concerns
Toileting concerns
Birth to 3 services
Preschool Special Education

Developmental — Any concern about your child’s

Concern	Yes	No
Physical development
Movement from one place to another
Social development
Emotional development
Ability to communicate needs
Interaction with others
Behavior
Ability to understand
Ability to use their hands

Have you talked with your child’s primary health care provider about any of the above concerns?

Yes No

Part II — Medical Evaluation

Health Care Provider must complete and sign the medical evaluation, physical examination and immunization record.

I have reviewed the health history information provided in Part I of this form

Physical Exam

Note: *Mandated Screening/Test to be completed by provider.

Screenings

Vision Screening

EPSDT Subjective Screen Completed(Birth to 3 yrs)

EPSDT Annually at 3 yrs(Early and Periodic Screening,Diagnosis and Treatment)

Unable to assess

Type	Left	Right
With glasses	20/	20/
Without glasses	20/	20/

Hearing Screening

EPSDT Subjective Screen Completed(Birth to 4 yrs)

EPSDT Annually at 4 yrs(Early and Periodic Screening,Diagnosis and Treatment)

Left

Pass Fail

Right

Pass Fail

Unable to assess

*TB: High-risk group?

yes no

Test done

yes no

*Dental Concern

yes no Referral made to:

*Lead: at 1 and 2 years; if no result screen between 25 – 72 months

History of Lead level

yes no

*Developmental Assessment: (Birth – 5 years)

yes no

IMMUNIZATIONS

Up to Date or Catch-up Schedule

Chronic Disease Assessment:

Asthma

No Yes
Intermittent Mild Persistent Moderate Persistent Severe Persistent Exercise induced

Rescue medication required in child care setting: No Yes

Allergies

No Yes

Epi Pen required: No Yes

History/risk of Anaphylaxis: No Yes
Food Insects Latex Medication Unknown source

Diabetes

No Yes Type I Type II

Seizures

No Yes

This child has the following problems which may adversely affect his or her educational experience:

Vision Auditory Speech/Language Physical Emotional/Social Behavior

This child has a developmental delay/disability that may require intervention at the program.

This child has a special health care need which may require intervention at the program, e.g., special diet, long-term/ongoing/daily/emergency medication, history of contagious disease.

This child has a medical or emotional illness/disorder that now poses a risk to other children or affects his/her ability to participate safely in the program

No Yes

Based on this comprehensive history and physical examination, this child has maintained his/her level of wellness

No Yes

This child may fully participate in the program

No Yes

Is this the child’s medical home?

No Yes

I would like to discuss information in this report with the early childhood provider and/or nurse/health consultant/coordinator.

Immunization Record

Vaccine	Dose 1	Dose 2	Dose 3	Dose 4	Dose 5	Dose 6
DTP/DTaP/DT
IPV/OPV
MMR
Measles
Mumps
Rubella
Hib
Hepatitis A
Hepatitis B
Varicella
PCV* vaccine
Rotavirus
MCV
Influenza
Tdap/Td

Disease history for varicella (chickenpox)

Exemption

Religious

Medical:Permanent

Temporary

Parent/Guardian Signature

Early Childhood Health Assessment Record

Part I — To be completed by parent/guardian

Developmental — Any concern about your child’s

Part II — Medical Evaluation

Physical Exam

Screenings

*Dental Concern

*Lead: at 1 and 2 years; if no result screen between 25 – 72 months

IMMUNIZATIONS

Chronic Disease Assessment:

Asthma

Allergies

Diabetes

Seizures

Immunization Record

Disease history for varicella (chickenpox)

Exemption

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