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GENERAL HEALTH APPRAISAL FORM
PARENT please complete AND SIGN
Child’s Name:_______________________________________________________ Birthdate: _____________________
Allergies: ‰ None or Describe___________________________________________________________________________________________
Type of Reaction ____________________________________________________________________________________________________ Diet: ‰ Breast Fed ‰ Formula _______________________ ‰Age Appropriate
‰Special Diet ________________________________________________________________________________________________
Sleep: Your health care provider recommends that all infants less than 1 year of age be placed on their back for sleep.
‰ Preventive creams/ointments/sunscreen may be applied as requested in writing by parent unless skin is broken or bleeding.
I, ________________________________________ give consent for my child’s care health provider, school child care or camp personnel to
discuss my child’s health concerns. My child’s health provider may fax this form (& applicable attachments) to my child’s school, child care
or camp personnel. FAX #: _____________________________ DATE: _____________________________

Parent/Guardian Signature___________________________________________________________________
HEALTH CARE PROVIDER: Please Complete After Parent Section Completed
Date of Last Health Appraisal: _____________________________ Weight @ Exam: _______________________________________
Physical Exam: ‰ Normal ‰ Abnormal (Specify any physical abnormalities)_____________________________________________________
Allergies: ‰ None or Describe__________________________ Type of Reaction __________________________________________________
6LJQLÀFDQW+HDOWK&RQFHUQV ‰Severe Allergies ‰Reactive Airway Disease ‰Asthma ‰Seizures ‰Diabetes ‰Hospitalizations
‰Developmental Delays ‰Behavior Concerns ‰Vision ‰Hearing ‰Dental ‰Nutrition ‰ Other ________________________________ Explain above concern (if necessary, include instructions to care providers): ______________________________________________________ Current Medications/Special Diet: ‰ None or Describe ______________________________________________________________________
Separate medication authorization form is required for medications given in school, child care or camp For Fever Reducer or Pain Reliever (for 3 consecutive days without additional medical authorization) PLEASE CHOOSE ONE PRODUCT
‰Acetaminophen (Tylenol) may be given for pain or fever over 102 degrees every 4 hours as needed 'RVHBBBBBBBBBBBBBBBBBBBBRUVHHWKHDWWDFKHGDJHDSSURSULDWHGRVDJHVFKHGXOHIURPRXURIÀFH OR ‰Ibuprofen (Motrin, Advil) may be given for pain or for fever over 102 degrees every 6 hours as needed
'RVHBBBBBBBBBBBBBBBBBBBBRUVHHWKHDWWDFKHGDJHDSSURSULDWHGRVDJHVFKHGXOHIURPRXURIÀFH Immunizations: ‰Up-to-Date ‰ See attached immunization record ‰Administered today: _____________________________________________
Health Care Provider: Complete if Appropriate
**ONLY REQUIRED BY EARLY HEAD START AND HEAD START PROGRAMS PER STATE EPSDT SCHEDULE**
** Height @ Exam _____ ** B/P _____ **Head Circumference (up to 12 months) _______ **
** HCT/HGB _____ ** Lead Level
‰Not at risk or Level _____
**TB
‰Not at risk or Test Results ‰ Normal ‰ Abnormal
**Screenings Performed: ‰Vision: ‰Normal ‰Abnormal ‰Hearing: ‰Normal ‰Abnormal ‰Dental: ‰Normal ‰Abnormal-
Recommended Follow-up________________________________________________________________________________________
Provider Signature
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Next Well Visit: ‰ Per AAP guidelines* or ‰ Age__________ This child is healthy and may participate in all routine activities in school sports, child care or camp SURJUDP$Q\FRQFHUQVRUH[FHSWLRQVDUHLGHQWLÀHGRQWKLVIRUP _____________________________________________________ Signature of Health Care Provider (certifying form was reviewed) Date: _______________ The Colorado Chapter of the American Academy of Pediatrics (AAP) and Healthy Child Care Colorado have approved this form. 04/07*The AAP recommends that children from 0-12 years have health appraisal visits at: 2, 4, 6, 9, 12, 15, 18 and 24 months, and age 3, 4, 5, 6, 8, 10 and 12 years.
Copyright 2007 Colorado Chapter of the American Academy of Pediatrics

Source: http://www.ckcs.net/preschool-images/info_copy/health_form2012.pdf

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