Childhood Pre-K Health Record Supplement* Name of Child: Name of Child Care Facility: Child’s DOB: To Be Completed By The Physician 1. Type Screening 2. Date 3. Results 4. Recommendations/Follow up Completed Head Circumference (up to 2yrs old) Normal Abnormal  Hgb/Hct Normal Abnormal  Lead Normal Abnormal  BMI (≥ 2 years old) Normal Counsel  Developmental Screening □ □ Tool: PEDS ASQ No Concern Concern   □ Other _________________________ 5. Medical Conditions 6. Special Care 7. Recommendations 8. EC Provider Plan Needed Use Only None  Allergies/Sensitivities  Special Care YesNo  List: Plan completed  None  Medications/Treatments  Special Care YesNo  List: Plan completed  None  Special Diet prescribed by physician Special Care  YesNo  List: Plan completed  None  Behavioral Issues/Social Emotional Concerns Special Care  YesNo  List: Plan completed  None Medical Conditions/Related Surgeries   Special Care YesNo  List: Plan completed  9. Physician/NP/APRN/PA or Clinic Name, Address, Zip, Phone, Fax 11. I give my consent for my child’s Health Care Provider to discuss the information on this form with my Early Childhood Provider _____________________________________________________________________________ Early Childhood Provider Name 12. Parent/Guardian Name 10. Physician/NP/ APRN/ PA or Clinic Signature (Signature or stamp) Date 13. Parent/Guardian Signature Date *Supplement to the STATE OF HAWAI‘I, DEPARTMENT OF EDUCATION, FORM 14, Rev. 2010, RS 09-1051 (Rev. of RS 06-0698) Instructions for Completing the Early Childhood Pre-K Health Record Supplement
Childhood Pre-K Health Record Supplement* Name of Child: Name of Child Care Facility: Child’s DOB: To Be Completed By The Physician 1. Type Screening 2. Date Completed 3. Results 4. Recommendations/Follow up Head Circumference (up to 2yrs old)  Normal Abnormal Hgb/Hct  Normal Abnormal Lead  Normal Abnormal BMI (≥ 2 years old)  Normal Counsel Developmental Screening Tool: □ PEDS □ ASQ □ Other _________________________  No Concern Concern  5. Medical Conditions 6. Special Care Plan Needed 7. Recommendations 8. EC Provider Use Only Allergies/Sensitivities  None List:  YesNo   Special Care Plan completed Medications/Treatments  None List:  YesNo   Special Care Plan completed Special Diet prescribed by physician  None List:  YesNo   Special Care Plan completed Behavioral Issues/Social Emotional Concerns  None List:  YesNo   Special Care Plan completed Medical Conditions/Related Surgeries  None List:  YesNo   Special Care Plan completed 9. Physician/NP/APRN/PA or Clinic Name, Address, Zip, Phone, Fax 11. I give my consent for my child’s Health Care Provider to discuss the information on this form with my Early Childhood Provider _____________________________________________________________________________ Early Childhood Provider Name 12. Parent/Guardian Name 10. Physician/NP/ APRN/ PA or Clinic Signature (Signature or stamp) Date 13. Parent/Guardian Signature Date *Supplement to the STATE OF HAWAI‘I, DEPARTMENT OF EDUCATION, FORM 14, Rev. 2010, RS 09-1051 (Rev. of RS 06-0698) Instructions for Completing the Early Childhood Pre-K Health Record Supplement
DHS%20908%20Form%20rev%2009-15%204%20pages%20DHS%20Website.docx