CHILD HEALTH ASSESSMENT

Do you need a Translator?

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How would you rate your child’s health in the past 6 months? Excellent Good Fair Sick occasionally Sick more than most children -- select an option --

Has your child been diagnosed with any of the following? Asthma Autism Spectrum Disorder Behavioral Health (Anxiety, Bipolar, Depression, Schizophrenia) Birth Defects Bronchitis Cancer Diabetes Down Syndrome Epilepsy/Seizure Disorder Heart Problems Kidney Disease Learning Disabilities Liver Disease Sickle Cell Anemia Transplant Other

Does your child have trouble with speech?

Is your child receiving services to help with their speech?

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Does your child have trouble with hearing?

Does your child use a hearing aid?

What type? Bilateral Left Right -- select an option --

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Does your child have trouble with vision?

Is your child able to see with glasses?

Does your child use any other assistive devices or services to help with their vision?

Device or service used:

Does your child use any other assistive devices for daily activities like dressing, eating, or walking?

Please explain other therapy

Does your child take any medications regularly?

What medications?

Does your child see a doctor for any behavioral health issues?

Has your child been hospitalized in the last 6 months?

Where and why?

Has your child been in the emergency room in the past 6 months?

How many times? 3 or more 1 - 2 -- select an option --

Where and why?

Has your child’s doctor ever told you that your child is overweight?

Is your child up-to-date on their immunizations?

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Was your child seen for a Well Visit in the past 12 months?

Why not? Lack of transportation Unable to get off work Unable to get an appt Other -- select an option --

Please explain

If your child is old enough to go to school, how often do they go? Most of the time Some of the time Rarely Never -- select an option --

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Do you need help getting enough food for your child?

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Does your child have safe, stable housing?

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Has your child experienced any trauma in the past 6 months?

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Do you have any other concerns about your child?