Child Health History

Child Health History Eastern Oregon Head Start * One University Boulevard * La Grande, OR 97850 * 541-962-3798 * Fax To: 541-962-3794 Child’s Name: ______Date: ______Classroom (if known): ______Information Obtained From: ______Taken By HS Staff:______Does your child have a doctor? No □ Yes □ Vision Difficulties: Doctor/Clinic Name:______□ Wears glasses Does your child have a dentist? No □ Yes □ □ Other: ______Dentist/Clinic Name:______Hearing Problems: Medication: Type: ______Condition Treated: ______□ Frequent ear infections Will Medication need to be kept at school? No □ Yes □ □ Discharge from ear Has your child had any of the following health conditions: □ Tubes in ear(s) □ Asthma ____Chronic ____Periodic □ Other: ______Inhaler needed at school? No □ Yes □ Developmental, Social, and Emotional Challenges □ Anemia or Sickle Cell Disease (Please explain any YES answers.) □ High Lead Level Have there been any big changes or problems in your or the □ Diabetes child’s life in the past year?

□ Epilepsy or Seizure Disorder Does the child have any suspected developmental delays? □ Serious Accident , Illness, Surgery, or Hospitalization Please explain: ______Does child require any special braces, equipment, or Allergies to: modifications to environment? □ Bees or other insects □ Food: ______Do you have social or emotional concerns about your child?

□ Medication: ______Has the child been evaluated by, or is this child currently □ Seasonal Allergies receiving services from another agency? ECSE □ □ Other: ______□ Dental concerns □ Heart or Liver Disease □ Tuberculosis □ Polio □ Measles, German Measles, or Mumps □ Meningitis □ Whooping Cough □ Scarlet Fever □ Rheumatic Fever □ Chicken Pox □ Hepatitis A or B □ Rotavirus □ Impetigo □ Eczema, Hives, Skin Problems □ Sinus Trouble, Frequent Runny Nose □ Hyperactivity, Trouble Sleeping □ Lack of Energy/Tired □ Fainting Spells □ Hemophilia or Bleeding Tendencies □ Bone, Joint or Muscle Injury or Disease □ Daytime Wetting, Bed Wetting, Wears Diapers □ Problems with Urination, Frequent, Painful, etc □ Frequent Fevers, Cough, Sore Throat, or Headaches □ Frequent Vomiting, Stomach Pain, Diarrhea, Constipation Return Completed Form to Health & Nutrition AND Disabilities Managers

Forms/Child Health and Development/Health and ERSEA/Student Records/Enrollment Packet/Health History Revised 2016