1. Center:_________________
File Number/Family Name:_________________
TELAMON CORPORATION
MIGRANT AND SEASONAL HEAD START: CHILD HEALTH HISTORY
Complete one entire Child Health History for each enrolled child. Complete este documento de los Datos de
la Salud del Niño para cada niño matriculado en el programa.
CHILD’S NAME:___________________________________________ DOB:______________________
I. Preliminary Questions
How much did this child weigh at birth?
1
Weight Status at birth
Yes No
Has anyone in the family ever had any serious illnesses or abnormalities (e.g. heart disease,
diabetes, cancer, tuberculosis, asthma, etc.)? If yes, please explain._________________________
________________________________________________________________________________
Yes No
Were there any problems with this child immediately after birth? If yes, please explain._________
________________________________________________________________________________
Yes No
Is your child taking any medications every day? If yes, please explain._______________________
________________________________________________________________________________
Yes No
Will medication be needed at school? If yes, please explain. _______________________________
________________________________________________________________________________
II. Has this child ever had the following illnesses? If so, please give date and explain below
Dates Dates Dates
Measles Ear/Nose/Throat Eye
Mumps Urinary/Kidney Heart
Chickenpox Muscle/Bone Pneumonia
Scarlet Fever Anemia Asthma
Respiratory Blood Pressure Diabetes
Tuberculosis Rheumatic Fever Intestinal
Seizures Bee Sting Allergy
Comments:
III. Has your child ever had the following? Check the box if yes, please give date and explain.
Hospitalizations
Operations
1
Low Birth Weight, Underweight, Within Normal Range, or Overweight
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Serious Injuries
Other Health Problems/Illnesses
Allergies to Medications(i.e.
penicillin, sulfa drugs) Specify:
IV. Developmental History: Check the box if your child... (choose all that apply)
Focused his/her eyes and followed light or objects with their eyes by 2 months?
Cooed and Gurgled by 3 to 4 months?
Sat alone on or before the 8th month?
Walked alone on or before the 15th month?
Said simple words on or before the 2nd year?
Was toilet trained on or before the 3rd year?
Does his/her mental development appear normal?
Do you have any concerns about your child's
behavior? If so, where? Home School Public
Child was evaluated or has received a behavioral health diagnosis?
Would you like to be contacted by a Behavior Health Specialist?
Explain/Comments:
V. Immunization History (Only Check One)
*Your child is up-to-date on all immunizations appropriate for his/her age?
*Your child has received all immunizations possible at this time but has not received all immunizations
appropriate for his/her age?
*Your child has received no immunizations.
None of the above
Explain/Comments:
VI. Dental Information
Yes No *Does your child have dental insurance? If yes, specify dental plan______________________
Yes No *Does your child have an Ongoing Source of Continuous and Accessible Dental Care?
Dentist Name
_____________________________________________________________ Date of last visit ___________________
Yes No
Were there any dental problems identified for your child? Comments: ______________________
_______________________________________________________________________________
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VII. Nutrition Assessment
Yes No 1. Does your child's weight appear normal?
Yes No 2. Does your child eat fruits and vegetables?
Yes No 3. Is your child a picky eater now?
Yes No 4. In the past six months, was your child found to be anemic (low blood iron)?
Yes No 5. Is your child involved in active play daily?
Yes No 6. Does your child have diarrhea frequently?
Yes No 7. Does your child have constipation frequently?
Yes No 8. Does your child vomit frequently?
Yes No 9. Does your child drink from a baby bottle now?
Yes No 10. Does your child have dental problems now?
Yes No 11. Does your child have difficulty chewing or swallowing now?
Yes No 12. Do you have concerns about your child's growth, nutrition or eating?
Yes No 13. Does your child eat solid food?
Yes No 14. Does your child drink from a cup?
Yes No 15. Does your child feed his or herself?
Yes No 16. Does your child use a pacifier? If yes, when:_______________________________________
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Indicate the approximate number of times daily your child eats from the following food groups:
Food Groups 0 1 2 3 4 5 6
Recom-
mended Follow-Up
1. Milk Group: Milk(Whole, 2%, 1%, skim)
yogurt, cheese, milkshakes) 3 ________________
2. Meat, Poultry, Fish, Dry Beans, Eggs:
Beef, chicken, turkey, pork, fish, eggs,
peanut butter, Nut Group: dried beans,
nuts, peas, lentils 2 ________________
3. Bread, Cereal, Rice & Pasta Group:
Bread (all kinds), hot or cold cereal,
crackers, tortillas, noodles or pasta (all
kinds), rice 4 ________________
4. Vitamin C Rich Group: Orange,
grapefruit, lemon, lime, strawberries,
tangerine, watermelon, mangoes,
tomatoes, cabbage 1 ________________
5. Other Fruits & Vegetables Group:
Apple, banana, pear, grape, peach,
potato, green beans, corn 3 ________________
6. Vitamin A Rich Group (per week):
Dark green or orange vegetables &
fruits such as greens, carrots, broccoli,
winter squash, spinach, pumpkin,
sweet potato, apricots, canned plums,
mangoes
3 per
week ________________
7. Fatty Foods: (a) Bacon, lunch meat,
sausage, hot dogs, fried foods (b)
butter/margarine, sour cream, regular
salad dressings, mayonnaise ________________
8. Soda and Flavored Drinks: Pop, kool
aid, fruit drinks ________________
9. Sugar and Sweets: Candies, cake,
cookies, high sugar cereals ________________
10. Salty Snacks: Chips, salted pretzels,
pickles ________________
VIII. Food Substitution
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Yes No 1. Is your child restricted from foods due to religious, vegetarian, medical or personal beliefs?
If yes, please check all that apply:
Pork Beef Poultry Fish Eggs Milk Other__________________
Yes No 2. Does your child have any food allergies or intolerances?
If yes, please check all that apply:
Milk Milk Products Eggs All foods containing eggs
Whole Wheat Wheat Gluten Fish Shellfish
Beef
Legumes (dry
beans/peas) Tree Nuts/Seeds Peanuts Soy
Vegetables, specify __________________________________________________________________________
Fruits/Juice, specify __________________________________________________________________________
Other, Specify _______________________________________________________________________________
3. If food allergy indicated, what kind of reaction does your child have when they child eat the food specified above?
Life Threatening Rash Diarrhea Swelling Difficulty Breathing
Other, specify _______________________________________________________________________________
Yes No 4. Is your child on any special diet prescribed by a doctor?
If yes, please specify: _____________________________________________________________________________
NOTE TO STAFF - If yes to questions 1, 2,3, and/or 4 above: - Substitutions for medical reasons will be
accommodated only with a signed statement from a licensed physician or other medical authority. Staff must give
physician's statement to parent.
Substitutions for non-medical reasons (i.e. religious, vegetarian, etc.) will be approved on a case-by-case basis with
the Health Coordinator or Nutritionist.
IX. Asthma / Allergy Screening
Yes No 1. Has your child ever been diagnosed by a medical professional as having asthma?
a) Date of diagnosis:____________________
b) How many episodes per year? _____________________
c) Is it seasonal? At what time of the year do the episodes most often occur? _______________
d) Is it well controlled? If so, how? _________________________________________________
Yes No
2. Has your child experienced any of the following due to asthma? If yes, please check the ones
that apply:
Treatment in ER If yes, then # of times:__________
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Hospitalizations If yes, then # of times:__________
Yes No 3. Have you ever given your child any medications for asthma?
If yes, please check all that your child has used in the last year:
Albuterol Intal
Ventolin Pedia Pred
Tedral Prelone
Proventil Primitine Mist
Marax Quiboron
Other, specify: ____________________________________________________________
Yes No 4. Does your child use a Nebulizer or Inhaler?
5. How many colds does your child have in a year? ___________
Yes No 6. Does your child suffer from hay fever or eczema?
Yes No 7. Is your child allergic to any of the following?
If yes, please check all that apply:
Animals Perfume
Birds Pollen
Grass Flowers
Dust Trees
Smoke Weather Changes
Other ___________________________________________________________________
Yes No Does anyone in the household smoke? (i.e. home/car)
Comments: ____________________________________________________________________
X. Medical Coverage
Yes No
*1.Does your child receive medical services through an ongoing source of continuous,
accessible medical care?
Yes No
2. Does your family have a regular doctor or a regular place to receive health services?
If yes, please answer the following
Doctor's name: ___________________________________ Phone #: ____________________
Address:_______________________________________________________________________
Date of last physical:_____________________________________________________
Check if your child receives services through one of the following:
Indian Health Services
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Migrant Community Health Centers
Yes No
3. Do you use the County Health Department for health care?
If yes, what city/county?__________________________ Date of last physical:_______________
Yes No 4. Do you have "regular" Medicaid/ TennCare /MiChild?
2
Outcome: _____________________
Yes No
5. Do you have “emergency only” Medicaid/ TennCare/
MiChild?
2
Outcome: _____________________
Yes No 6. Do you have Healthy Families SCHIP?
2
Outcome: _____________________
Yes No
7. Do you have private / other health insurance?
If yes, what is the name of the insurance? ____________________________________________
Comments:
XI. Health History Consent Section
Do you give your permission to Telamon Corporation to obtain/perform the following services for your child?
Yes No 1. Dental screening/exam and treatments (to detect problems with teeth and gums).
Yes No 2. Vision screening/exam (to detect problems with vision).
Yes No 3. Auditory/Hearing screening (to detect problems with the ears).
Yes No 4. Blood pressure screenings (if not noted on the physical exam).
Yes No
5. Nutrition/growth screening and referral (to detect problems with delayed
growth/overweight/underweight children).
Yes No 6. Speech and language screenings (to detect problems with speaking and understanding).
Yes No
7. Developmental screening (to assess levels in language, cognition, visual, small motor, gross
motor, social, and emotional aspects).
Yes No 8. Mental Health (Classroom observations)
Yes No
9. In cases of emergency medical/dental care, I give my permission to Head Start staff to secure
needed emergency medical care if parents/guardian cannot be immediately contacted.
Yes No
10. Exchange of child’s information with school systems, health centers, other Head Start, and
preschool programs.
Yes No
11. To transport children by Head Start staff on the bus to field trips, medical, dental or
emergency services.
Yes No 12. Lead Testing (Blood Lead Level)
Yes No 13. Tuberculosis Test
Yes No 14. Blood Test (Hematocrit/Hemoglobin)
Yes No 15. Use of child’s photograph or video tape image for program purposes.
2
In Process, Enrolled, Denied, Ineligible, or Refused
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Yes No 16. Transport child to/from center from home.
Yes No 17. Immunizations
Yes No 18. Physical exam and treatments
Comments:
Telamon Health History Addendum (This information is input into COPA in the User Defined tab under the child)
Check all that apply.
Child has a continuity record.
Child was considered premature at birth.
Child uses or has used a wheelchair.
Child has glasses or contact lenses.
Child uses or has used braces.
Child uses or has used crutches, a walker, or a cane.
Child uses a hearing aid.
Child uses or has used an Apnea monitor.
Child has nightmares.
Child has problems wetting the bed.
Child has problems with breath holding.
Child has speech problems.
Child has difficulty sleeping.
What type of milk does your child drink? (check all that apply)
regular milk breast milk Formula. Type________________________
NOTE: Doctors order required for:
Children under 12 months on regular milk OR Children over 12 months on formula
Age 0-12 months only – How many times a day does your child eat?________________________________________
Age 0-12 months only – How many ounces does your child consume in 24 hours?_____________________________
Age 0-12 months only - What other type of food does your child consume? (if any)
_______________________________________________________________________________________________
_______________________________________________________________________________________________
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Signed by Staff:_______________________________________________________ Date:_______________________
Signed by Parent/Guardian:_____________________________________________ Date:_______________________
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Signed by Staff:_______________________________________________________ Date:_______________________
Signed by Parent/Guardian:_____________________________________________ Date:_______________________
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