WHITE BEAR LAKE AREA SCHOOLS

Independent School District #624

HEALTH HISTORY, DEVELOPMENTAL AND FAMILY FACTORS

Consent for Screening and Release of Information

Screening will consist of a health and developmental history, an immunization review, height and weight measurements, hearing and vision testing, a developmental screening including fine and gross motor, self-help skills, receptive and expressive language, kindergarten readiness, and a family factors review. Information obtained in this screening is classified as private and is available only to the child’s parent(s) or guardian in accordance with the Family Educational Rights and Privacy Act (1974). Legally, you are not required to release this information to anyone. Private information and records cannot be discussed or released to anyone except as authorized by the parent(s) or guardian.

Summary Data or Individual Data May Be Used By The School District For The Following Purposes:

  • To facilitate counseling or other follow-up services which you may wish to obtain after the screening
  • To transmit helpful information to another provider of services if a referral is made for further evaluation
  • To permit evaluation of the screening program by the local school district
  • To provide access to and accountability for government funds paid to the local school district for providing required ECS services

By signing this statement I consent to the screening as described above and to the release of the results of the screening to the school district to be used for permanent school health and developmental records, in addition to the above stated purposes.

Signature of parent or legal guardian______Date______

GENERAL INFORMATION

Child’s Name______Sex______Birthdate______

Parent/Guardian #1______School child will attend______

Address______

Home Phone______Work Phone______

Parent/Guardian #2 and Address (if different) ______

______

Home Language______

Child’s Doctor or Clinic______Date of last physical examination ______

Diagnosis______

Health Insurance Yes / No Name of Provider______

Past or present services from:Public Health NurseHome CareWIC/MACOther

Dentist ______Date of last examination ______

Optometrist or ophthalmologist ______Date of examination______

Is your child attending:Day CarePreschoolHead StartECFEOther

Attending where and how often______

Have you participated in Early Childhood Family Education classes? Yes / No

PAST MEDICAL HISTORY

Pregnancy and Birth

YesNoWas child adopted? If yes, at what age?______

YesNoDid child’s mother have difficulties during labor and/or delivery? If yes, describe______

______

YesNoDid your child weigh less than 5 pounds? Child’s birth weight______

YesNoDid your child stay in the hospital after mother was discharged? If yes,describe______

Growth and Development

Age your child did the following:

______Babble and Coo______Walks Alone

______Sit with Support______Beginning to Talk

______Stand with Support______Toilet Trained

Do you think your child should be doing more than he/she is doing for his/her age? Yes / No

If yes, please explain______

Childhood Illnesses

Has your child had any of the following Diseases?

Yes NoChicken PoxYes NoPneumonia

Yes NoGerman or 3-Day MeaslesYes NoRed or Hard Measles (Rubella)

Yes NoHigh Fever (104 degrees longer than 2 days)Yes NoRheumatic Fever

Yes NoMeningitisYes NoScarlet Fever

Yes NoMumpsYes NoStrep Infections

Yes NoWas your child ever hospitalized? If Yes, when and why? ______

______

Yes NoHas your child had other illnesses in which he/she was not hospitalized? If yes, what and when?______

Special Health Care

Yes NoDoes your child have any physical limitations or restrictions? If yes, what?______

______

Yes NoHas your child undergone any special tests for health problems? If yes, what?______

______

Yes NoIs your child taking medication regularly? If yes, what?______

______

Allergies

Yes NoHas your child ever had problems with allergic reactions to foods, airborne pollens, insects, medications? Please state age and type of reaction______

Yes NoDoes your child take any medications related to allergies?______

Accidents

Yes NoHas your child ever had any serious accidents or injuries? Describe______

______

Yes NoDoes your child have frequent accidents? Describe______

______

Yes NoHas your child ever become poisoned? describe______

______

Safety Practices

Yes NoDo you know Poison Control Access phone numbers?

Yes NoDo you use car seats/seat belts?

Yes NoDo you have smoke detectors in place and are they working?

Medical/Counseling Therapy Services

Is your child/family receiving services from the following or have they in the past? If yes, please give information where specified.

Yes NoMedical Specialist

Yes NoOccupation, Physical or Speech Therapist

Yes NoSocial Worker, Case Manager, Psychologist/Counselor

Yes NoIs your family participating in a group? Type of Group:______

Family History (Circle all that apply)

AllergyDeafnessHeart problemsMental DisordersReading problems

AsthmaDiabetesHemophiliaCognitive DelaysRheumatic fever

CancerEpilepsyMuscular dystrophySickle cell anemiaHepatitis

Cleft lip or palateEye abnormalitiesOther blood disordersThalassemia

Cystic Fibrosis Growth problemsHigh Blood PressureOther family diseasesTuberculosis

Are there other family members who have had the same or similar physical/developmental concerns?Yes No

Are there other children in your family who may have developmental problems?Yes No

Present Health

Nutrition/Sleep/Energy

YesNoDo you have concerns about your child’s nutrition/eating habits?

YesNoDoes your child have excessive thirst?

YesNoDoes your child have a sleep problem?

YesNoDoes your child have too much or too little energy? Which? ______

YesNoDoes your child have food allergies? What? ______

YesNoDoes your child take a vitamin/mineral supplement? What? ______

YesNoDoes your child have a normal appetite? If no, has it changed recently or has it always been this way? ______

YesNoIs your child on a special diet? What?______

YesNoDo you have any concerns regarding your child’s eating habits or diet? ______

How many meals does your child eat per day? ______Snacks per day? ______

Skin

YesNoDoes your child have problems with hives, rashes or eczema?

YesNoDoes your child bruise easily?

YesNoDoes your child have any unexplained lumps or spots?

Eyes/Ears/Nose/Throat/Dental

YesNoDoes your child have any problems with his/her eyes?

YesNoHas your child had 2-3 episodes of ear problems in a year?

YesNoHas your child had an earache or discharge from the ears within the past 6 months?

YesNoDoes your child seem to have any trouble hearing?

YesNoHas your child ever had PE tubes in his/her ears?

YesNoHas your child had 2 or more throat infections in a year?

YesNoDoes your child have frequent nose bleeds?

YesNoDoes your child get swollen glands frequently?

YesNoDoes your child have trouble with teeth, gums or mouth?

Respiratory

YesNoHas your child had 6-8 colds in a year?

YesNoDoes your child get a severe cough with colds?

YesNoDoes your child have trouble getting rid of a severe cough?

YesNoDoes your child have shortness of breath at times, asthma, or wheezing problems?

Cardiovascular

YesNoDoes your child have heart trouble?

YesNoDoes your child have a known heart murmur?

Gastrointestinal

Does your child have frequent:

YesNoStomach acheYesNoConstipation

YesNoDiarrheaYesNoVomitting

Urinary

YesNoDo you have any concerns about your child’s toileting?

YesNoDoes your child’s urine have a strong or unusual odor?

YesNoHas your child ever had kidney or bladder problems?

Skeletal

YesNoDoes your child complain of pains in his/her legs, arms, back or joints?

YesNoHas your child had any broken bones, cast, brace or corrective shoes?

YesNoDoes your child toe in, toe out, limp or walk with difficulty?

Neuromuscular

YesNoDoes your child lose his/her balance in unusual ways?

YesNoDoes your child have any unexplained movements or jerks, staring spells, seizures, falls or weakness in body?

Lead

YesNoHas your child been tested for lead? Where and results?______

YesNoDo live or have you lived in a house or apartment built before 1960?

YesNoHas your house or apartment recently been painted, sanded or had paint removed?

YesNoDoes your child try to eat non-food items (examples: dirt, tobacco, pencils, etc.)

Parent Comments

  1. Things about raising my child that are challenging:
  1. I would like my child to learn or get better at:
  1. When I need help with my family, I:
  1. Has any member of your family witnessed or experienced family or neighborhood violence?
  1. Has there been unusual stress in your family that might affect your child? (examples: new sibling, divorce, death of a family member, moving, financial problems, not enough food, etc.)

Any additional concerns/information you would like to discuss: