F.A.L.L.S. Cooperative Preschool
Child’s Name: ___________________________Sex: [ ] M [ ] F Birthdate ________________ Today’s Date __________
C HILD
’
S H EALTH H ISTORY
1. Name of Doctor __________________ Address/City/State _______________________ Phone Number ____________
2. Were there any significant problems during pregnancy or birth?
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Yes
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No If yes, please explain _________
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3. Has your child had surgery or been hospitalized?
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Yes
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No Date: _____________________________________
MEDICATION
4. Does your child take medication on a regular basis?
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Yes
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No Reason _____________________________________
5. Name of medication(s), dosage and when taken _________________________________________________________
6. Has your child had the following? If yes, put letter of item, age of child and description a. Asthma
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Yes
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No _______________________________________________________________________________ b. Other breathing problems
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Yes
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No __________________________________________________________________ c. Seizures or other neurological problems
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Yes
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No ________________________________________________________ d. Heart or other cardiovascular problems
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Yes
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No ________________________________________________________ e. Bladder or urinary tract problems
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Yes
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No ____________________________________________________________ f. Bowel or other GI problems
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Yes
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No ________________________________________________________________ g. Bone or joint problems
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Yes
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No ____________________________________________________________________ h. Eczema or skin problems
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Yes
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No __________________________________________________________________ i. Frequent ear infections or tubes
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Yes
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No ______________________________________________________________ j. Other ear, nose or throat problems
� Yes � No ____________________________________________________________ k. Tuberculosis exposure
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Yes
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No ____________________________________________________________________ l. Chicken Pox or vaccination for such
� Yes � No __________________________________________________________ m. Diabetes or other endocrine problems
� Yes � No _________________________________________________________ n. Injury or Abuse
� Yes � No _________________________________________________________________________ o. Car Sickness
� Yes � No ___________________________________________________________________________
Other/describe: _____________________________________________________________________________________
NUTRITION HISTORY
7. Is there any food or drink that your child should not eat for cultural, religious, personal or medical reasons other than allergies?
(Note: Use the “Allergy Chart” on the next page to list any allergies to food or drink)
� Yes – complete the lines below � No – go to question 8
___________________ [ ] Cultural [ ] Religious [ ] Medical/describe ____________________________
___________________ [ ] Cultural [ ] Religious [ ] Medical/describe ____________________________
___________________ [ ] Cultural [ ] Religious [ ] Medical/describe ____________________________
8. Does your child have any problems with chewing or swallowing? � Yes � No
Please describe _____________________________________________________________________________________
9. Check the box if you have concerns about your child’s: � Eating habits � Height � Weight
Please describe _____________________________________________________________________________________
OVER

ALLERGY HISTORY
10. Does your child have allergies or reactions (including intolerances) to food, medicine, insects, animals or other substances?
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Yes – please complete Allergy Chart below
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No – skip to Dental History, question 12.
11. ALLERGY CHART Note: If your child has a food or milk allergy, we must have written documentation of the allergy from the doctor. For milk allergies, the doctor must also name a substitute for the milk.
11a. Do you keep epinephrine (epi-pen) available at home for your child’s allergy? � Yes � No
List Each Allergy or Food Separately and Briefly describe child’s reaction and/or check symptoms Potential Severe Reaction*
Doctor and Date of Diagnosis_____________________________________________________________________
� Hives � Wheezing � Runny Nose � Shortness of Breath � Yes � No
� Hives � Wheezing � Runny Nose � Shortness of Breath � Yes � No
�
Hives
�
Wheezing
�
Runny Nose
�
Shortness of Breath
�
Yes
�
No
� Hives � Wheezing � Runny Nose � Shortness of Breath � Yes � No
� Hives � Wheezing � Runny Nose � Shortness of Breath � Yes � No
�
Hives
�
Wheezing
�
Runny Nose
�
Shortness of Breath
�
Yes
�
No
� Hives � Wheezing � Runny Nose � Shortness of Breath � Yes � No
* If the allergy has the potential to be severe, the child’s health care provider should complete a medical statement and an allergy care plan should be completed.
Additional information about allergy
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DENTAL HISTORY
12. Name of Dentist _____________________________ Address/City/State ___________________________ Phone # ___________
13. How would you rate your child’s dental health? � Very good � Somewhat good � Fair � Somewhat bad � Very bad
14. Has your child ever had an injury to the teeth or gums? � Yes � No
15. Has your child complained about pain in the teeth or gums? � Yes � No
16. Is there fluoride in the water at your home, or is your child taking a prescribed fluoride supplement? � Yes � No
PARENTAL CONCERNS
17. Do you have any concerns about your child’s vision? �
Yes
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No Please describe ______________________________________
18. Do you have any concerns about your child’s hearing? � Yes � No Please describe _____________________________________
19. Do you have any concerns about your child’s speech? � Yes � No Please describe _____________________________________
20. Do you have any concerns about your child’s behavior? �
Yes
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No Please describe ____________________________________
21. Do you have any concerns about your child’s development? � Yes � No Please describe _________________________________
22. Do you have any other concerns about your child? � Yes � No Please describe ________________________________________
Additional information regarding concerns:
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