Fort Belknap Head Start Program
Individual Child Health History
Child’s Name:
Head Start Center:
Date of Birth:
Phone Number:
Title:
Name of Interviewer:
1.
2.
3.
4.
Name of Person Interviewed:
Date and Time of Interview:
Relationship to Child?
Language Primarily Spoken In the Home?
(Place an “X” in the appropriate space If more than one
Date:
Time:
English:
Spanish:
Native:
Other:
please specify?)
5.
Primary Source of Health and Emergency
Care (Incudes Physician, Clinic, Dental, Emergency
Room, Etc.)
Doctor’s Name:
Clinic/ER:
Dentist
6. Source of Services Utilized:(Place an “X” that answers either yes or no in the boxes below)
EPSDT/MEDICAID:
Yes
Blue Chips:
Yes
Federal/State/Local Agency:
Yes
Social Security Income:
Yes
Personal Insurance (Blue Cross, Colonial Insurance, Etc.):
Yes
7. Does child have a current physical examination?
Yes
8. Does child have a current dental examination?
Yes
Pregnancy/Child Birth History
9. Did mother have any health problems during pregnancy or delivery?
Yes
10. Did mother visit physician fewer than two times during pregnancy?
Yes
11. Was child born more than 3 weeks early or late?
Yes
12. Was anything wrong with child at birth?
Yes
13. Was anything wrong with child in the nursery?
Yes
14. Did child and mother stay in hospital for medical reasons longer than
Yes
usual?
15. Is mother pregnant now?
Yes
If answered “yes” to questions 12, 13, and 14 please explain “yes” answers:
Hospitalizations and Illness
16. Has child ever been hospitalized or had surgery?
If yes please describe:______________________________________
17. Has child ever had a serious accident? (broken bones, head injuries, falls,
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
Yes
No
burns, poisoning?)
18. Has child ever had a serious illness?
Yes
If answered “yes” to any of the questions, please explain answers:
No
Possible Health Problems (Please circle any possible health issues)
19. Does child have frequent?: Sore Throat, Cough, Urinary Infections or Trouble
Yes
Urinating, Stomach Pain, Vomiting, Diarrhea
Does child have difficulty seeing? (Squint, cross eyes, look closely at objects)?
20.
21. Does child wear or need glasses?
22. Does child have problems with his/her ears? (earaches, discharge, etc.)
23. Have you ever noticed child scratching his/her behind (rear end, butt, anus)
while asleep? (Possible sign of worms)
24. Has child ever had a convulsion or seizure and if so is the child taking
medication for seizures?
25. Is child currently taking any medication? If so how often and dosage?
Medicine:__________________Dose:_________________
26. Has child ever had: Boils, Chickenpox, Eczema, German Measles, Measles, Scarlet
27.
Fever, Whooping Cough, Head Lice, H-Pylori, Hives, Polio?
Does child have any of these conditions: Asthma, Bleeding Tendencies,
Diabetes, Epilepsy, Heart/Blood Vessel Disease, Liver Disease, Rheumatic Fever, Sickle
Cell Disease, Pre-Hypertension or Hypertension, Teeth & Gum Problems
Does child have any outdoor type allergies? (Animal dander, dust, pollen, etc.)
28.
29. Is there any other medical condition/possible disability you think your
child might have?
Please Describe:___________________________________
No
Yes
Yes
Yes
Yes
No
No
No
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
Yes
No
No
Physical, Psychological, and Social Development
“These questions will help us understand your child better and know what is usual for him/her and what might not be usual so
that we can provide the best possible service for your child.”
Form Developed by Ron Doney FSM 03/29/12
30. Does your child take a nap? If so how long:_____________________
31. Does your child sleep less than 8 hours a day? Does he/she try to stay up
late at night? Does he/she suffer from nightmares?
32. Is your child toilet trained?
33. Does your child tell you when he/she needs to use the toilet?
34. Does your child have any difficulty speaking? Do you have trouble
understanding what your child is trying to communicate to you?
35. Children sometimes get cranky or cry when they’re tired, hungry, or
sick. Does your child cry or get cranky at times when you can’t figure out
why?
How do you help your child feel better?__________________________
36. Does your child have a lot of worries or is he/she afraid of anything?
If yes please describe:________________________________________
37. Have there been any big changes in your child’s life the past 6 months?
If yes please describe:________________________________________
38. Are there any possible family problems that might affect your child?
If yes please explain:_________________________________________
39. Does your child interact with other children his/her own age?
40. Does your child interact with other adults? (Grand parents, Uncles, Aunts,
Daycare Providers, etc.)
41. How does your child behave around other adults and or children
he/she might not know?
42. What type of activities does your child like to do?
43. Is there anything else you would like us to know about your child?
Yes
Yes
No
No
Yes
Yes
Yes
No
No
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
Yes
No
No
Nutrition Assessment
Please list your child’s favorite foods?
Are there any types of food your child dislikes?
Please circle the best answer
A
B
C
D
How would you describe your child’s appetite?
How many days does your family eat meals together per
week?
How would you describe meal times with your children?
Good
1-2
Fair
3-4
Poor
5-6
Everyday
Always
pleasant
1
Yes
Usually
pleasant
2
No
Sometimes
pleasant
3
Never
pleasant
4 or more
0 oz.
0 oz.
1-3 oz.
1-3 oz.
4-6 oz.
4-6 oz.
7 oz. or more
7 oz. or more
Public
Well
Home
Systemprocessed
Commercially
bottled
Yes
No
Yes
No
Yes
No
How many snacks does your child eat per day?
Does your child take a bottle to bed at night or carry a
bottle around during the day?
How much juice does your child drink per day?
About how much sweetened beverage (fruit punch, soft
drinks etc.) does your child drink per day?
What is the source of water your child drinks?
Does your child have any food allergies?
If answered yes please list:_______________________
Are you aware some foods are choking hazards for
children 5 yrs old or younger?
Does your child have a TV in his/her bedroom?