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Health Assessment
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Health Assessment
Child's Health Assessment
Child's Name
(Required)
First
Birthday
(Required)
MM slash DD slash YYYY
Any known allergies:
Medication
Yes
No
If yes, please list
(Required)
Medication
Foods
Yes
No
If yes, please list
(Required)
Foods
Other
Yes
No
If yes, please list
(Required)
Other
Any food sensitivities
Yes
No
If yes, please list
(Required)
Any food sensitivities
Any chronic illnesses or medical conditions:
Asthma
(Required)
Yes
No
Diabetes
(Required)
Yes
No
Seizures
(Required)
Yes
No
Heart problems
(Required)
Yes
No
Other:
Any disabilities:
Hearing impairment
(Required)
Yes
No
Visual impairment
(Required)
Yes
No
Developmental Delays
(Required)
Yes
No
Physical impairment
(Required)
Yes
No
Emotional Problems
(Required)
Yes
No
Diagnosed Psychological
(Required)
Yes
No
Disorders
(Required)
Yes
No
Other disorders or concerns we might need to know about:
Any additional health information not listed above:
Any medications your child is taking:
Any instructions for your child's daily care:
Date of last physical exam:
MM slash DD slash YYYY
Child's Medical Provider
Name
First
Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
Date of last dental exam:
MM slash DD slash YYYY
Child's Dental Provider
Name
First
Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
Any instructions for your child's emergency care?
Original Signature:
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Parent/guardian signature
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Date
MM slash DD slash YYYY
Getting to Know Your Child
1. Does your child have a nickname?
2. If parents are not married who does your child live with?
3. If there anyone not allowed to pick up your child?
4. Are there any specific holidays that you do not celebrate?
5. Has anything traumatic happened in your child's life that you feel may help us in taking care of your child?
6. Does your child have any special needs you would like his/her teacher to know about?
7. Is there any foods your child should not eat do to religious or personal beliefs?
8. Does your child have a special blanket or toy for sleeping?
9. What language is spoken in the home?
10. If your child speaks another language, does he/she understand English?
Please bring a picture of your family for your child's classroom -Thank You
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Name
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Ogden Center
(801) 893-9126
(801) 399-4448
E-mail
160 9th St, Ogden, UT 84404
6:30 a.m. - 5:45p.m. (Mon - Fri)
South Ogden Center
(801) 810-2794
(801) 479-0409
E-mail
5820 Wasatch Dr, South Ogden, UT 84403
6:45 a.m. - 5:45p.m. (Mon - Fri)
Home
About Us
About Us
Curriculum
Careers
Tuition Support
Why Choose Us
Programs
Infants & Toddlers
Twos
Threes & Pre-K
Kindergarten
School Age
Careers
Locations
Ogden Center
South Ogden Center
Parent Corner
Contact Us
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