RIVER VALE SCHOOL DISTRICT
CHILD STUDY TEAM
PRE-K HEALTH HISTORY AND ASSESSMENT
DATE:
I. STUDENT PROFILE:
Child’s Name: ____________________________________
Date of Birth: _________________
Age: ________
Sex:
Height__________
Weight_________
M
Mother’s Name:
Father’s Name:
Siblings Name:
Age: _________________
F
Age: _________________
II. REASON FOR REFERRAL:
(Referred by :______________________________)
Primary area of concern:
Expressive language
Receptive language
Social skills development
Behavior difficulties
Other:
Secondary area of concern:
Explain:
III. HEALTH PROBLEMS:
(List and describe any health problems and their management/treatment.)
IV. MEDICAL HISTORY:
Hospitalization
(List with dates and age)
(include reason, overnight stay, emergency room visit, outpatient, same day surgery)
Illness (include contagious disease, high fever, etc.)
Injuries (accidents, ingestions, head injury, etc.)
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Pre-K Health Assessment
03/06
IV. MEDICAL HISTORY (CONTINUED):
(List with dates and age)
Medications (include name and dosage)
Allergies
Date of last health care visit:__________________ Name of Provider:
Purpose of visit:_____________________________________________________________________
Dental Care: Has child seen dentist?
No
Yes
Date:
V. BIRTH AND DEVELOPMENTAL HISTORY:
1. Birth weight: _____pounds______ounces
2. Gestation (Duration of Pregnancy) _________weeks or ________months
3. Pregnancy: Maternal age:_________
# of pregnancies_________
4. Habits during pregnancy: (circle if applicable) smoking, drinking, drugs, other (Please explain):
5. High risks: (circle) infections, bleeding, high blood pressure, anemia, fever, RH factor,
trauma, inherited disease, medications, excessive weight gain, chronic disease, diabetes, hospitalization,
other (Please explain):
6. Labor and Delivery problems?
None
Yes: (Please explain):
________________________________________________________________________________
7. Neonatal problems: (circle) Breathing, infections, RH factor, jaundice, transfusions, bleeding,
congenital anomaly, feeding, other: (Please explain)
________________________________________________________________________________
8. Development: (Please state age if known)
Sat alone:
Crawled:
Stood:
Walked alone:
First words:
Spoke in sentences:
Toilet trained:
Other:
Coordination difficulty:
No
Yes (Please explain)
(E.g., fine motor, large muscle, other areas of concern)
________________________________________________________________________________
Is development
faster,
slower or
equal to siblings or peers?
Comments:
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VI. FAMILY HEALTH HISTORY:
Please check any applicable familial diseases:
heart disease
stroke
hypertension
diabetes
allergy
anemia
sickle cell disease or trait
cancer
epilepsy
cataracts
glaucoma
tuberculosis
learning disabilities (please explain):
asthma
arthritis
kidney disease
_______________________________________________________________________________________
_______________________________________________________________________________________
VII. HABITS:
Thumb sucking
Other:
Nightmares
Other:
Sleepwalking
Rocking
VIII. REVIEW OF SYSTEMS:
1. General: Changes in weight, appetite, activity level, bowel habits, resistance to disease. Explain:
2. Birth Defects: Congenital anomalies. Explain:
3. Skin: Rashes, easy bruising, changes in skin color or texture, eczema, impetigo, growths, or tumors.
Explain:
4. Head: Headache, trauma, infections. Explain:
5. Eyes: Vision changes, trauma, infections, cataracts, glaucoma, other Explain:
6. Ear, Nose, Throat: Infections (specify), trauma, epistaxis, allergies, hearing changes, voice changes,
caries, and speech problems. Explain:
7. Neck: Trauma, swollen lymph nodes, limitation of movement. Explain:
8. Respiratory: Infections, breathing problems, trauma, wheezing, cough, asthma. Explain:
9. Cardiovascular: Murmur, fatigue with exertion, cyanosis. Explain:
10. Gastrointestinal: Abdominal pain, nausea, jaundice, vomiting, diarrhea, constipation, ulcer. Explain:
11. Genitourinary: Infections, enuresis, encopresis, discharge, rashes, menstruation, sexual
development. Explain:
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Pre-K Health Assessment
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VIII. REVIEW OF SYSTEMS (CONTINUED):
12. Musculosketal: Trauma, limitation of movement, joint pain or swelling, growths or tumor, curvature
of the spine, braces, corrective shoes. Explain:
13. Neurological: Birth injury, trauma, seizures (febrile vs afebrile) staring speels, poor coordination or
balance, dizziness, syncope, developmental evaluation. Explain:
14. Endocrine: Increased thirst, appetite, urination, diabetes, thyroid problems. Explain:
15. Hemotologic: Anemia, blood transfusions, blood dyscrasias, sickle cell. Explain:
16. Psychosocial: Changes in activity level, behavior, relationships, punishment, rewards. Explain:
17. Nutrition: (24 hour recall including snacks):
IX. VISION SCREENING:
Has the child visited an eye doctor?
No
Yes Date of visit:
Comments:
Does the child wear glasses?:
No
Yes
Left
Date started wearing glasses:
Right
Both
Without Correction:
WO 20/
WO 20/
WO 20/
With Correction:
W 20/
W 20/
W 20/
X. HEARING SCREENING:
Has the child had frequent ear infections?
Threshold Test on:
500
1000
No
2000
Yes
How often?
3000
4000
Right
Left
Comments:
How was the child’s behavior during the Vision and Hearing Screenings (e.g., restless, cooperative, crying,
etc.) Explain:
Completed by:
Mrs. JoAnn Hirsch, R.N., M.S.N.
Certified School Nurse
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Date
Pre-K Health Assessment
03/06