Child’s Health Assessment Report
For Covenant Christian Preschool
Childs Class and Teacher: _______________________________________
PARENT COMPLETE:
Child’s Name: _____________________________________________________________________
(Last)
(First)
(Middle)
Birth Date: ____/____/____ (mm/dd/yyyy)
Medical History:
if yes please have your Health Care Provider attach an Asthma Action Plan
Allergies:
_______________________________________________
o_________
o(such as animals):_________________________________________________
oDate of child’s last WELL CHILD CHECK UP:_______________________________
Is there any evidence of:
Hearing loss or difficulties? __________________________________________
Vision difficulties? _________________________________________________
Speech disabilities? ________________________________________________
Is the child free fr
List any medications or drugs taken regularly by the child: _______________________
______________________________________________________________________
Other remarks regarding physical condition: ___________________________________
______________________________________________________________________
The above information is correct as of: ____/____/____ (mm/dd/yyyy)
Health Care Professional’s Certification-Attach a copy of immunization record.
I certify that the information on this form is accurate and complete to the best of my
knowledge.
Provider’s Name: __________________________________________
Provider’s Signature: _______________________________________Date:____________
Provider Stamp Here