HEALTH HISTORY ANNUAL UPDATE FORM Last, First Middle Name: D.O.B.: Sex: M F 1 Has your child been ill or hospitalized in the last year? If yes, why and when? Yes No 2 Is your child taking medication? If yes, what? Yes No 3 Are there any health concerns or issues regarding your child If yes, what? Yes No you want to discuss? 4 Has your child developed any allergies? If yes, what foods? Yes No If yes, what drugs? If yes, what other allergies? 5 Does your child currently have tubes in their ears? If yes, when were they inserted? Yes No 6 Does your child wear diapers or pull-ups at any time? If yes, what do they wear and when? Yes No 7 Primary Health care provider (list if changed): 8 Dental Health care provider (list if changed): 9 Current/Medicaid/Insurance Coverage (list if changed): 10 Complete new Health Care Plans / Medical Alerts Yes Comments: Not applicable 11 Complete new Request for Special Dietary Accommodations Yes Comments: Not applicable 12 History part on Nutrition History & Assessment form is Comments: Yes reviewed/updated Not applicable 13 Complete new Medication Consent & Chart form Yes Comments: Not applicable 14 Complete Toileting Plan Yes Comments: Not applicable 15 Additional Comments Parent/Guardian signature: Date: Staff signature: Date:
HEALTH HISTORY ANNUAL UPDATE FORM Last, First Middle Name: D.O.B.: Sex: M F 1 Has your child been ill or hospitalized in the last year? Yes No If yes, why and when? 2 Is your child taking medication? Yes No If yes, what? 3 Are there any health concerns or issues regarding your child you want to discuss? Yes No If yes, what? 4 Has your child developed any allergies? Yes No If yes, what foods? If yes, what drugs? If yes, what other allergies? 5 Does your child currently have tubes in their ears? Yes No If yes, when were they inserted? 6 Does your child wear diapers or pull-ups at any time? Yes No If yes, what do they wear and when? 7 Primary Health care provider (list if changed): 8 Dental Health care provider (list if changed): 9 Current/Medicaid/Insurance Coverage (list if changed): 10 Complete new Health Care Plans / Medical Alerts Yes Not applicable Comments: 11 Complete new Request for Special Dietary Accommodations Yes Not applicable Comments: 12 History part on Nutrition History & Assessment form is reviewed/updated Yes Not applicable Comments: 13 Complete new Medication Consent & Chart form Yes Not applicable Comments: 14 Complete Toileting Plan Yes Not applicable Comments: 15 Additional Comments Parent/Guardian signature: Date: Staff signature: Date:
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