Kindergarten Health History Template - Multicare Associates Page 2
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415. Has this child ever been exposed or had contact with a person with tuberculosis?. . . . . . . . .
YES
NO
16. Has this child ever had or does this child have: (please circle)
Constant cold
Trouble urinating
Heart Trouble
Difficulty hearing
Wheezing or asthma
Kidney or Bladder infection
Rheumatic Fever
Diabetes
Eczema or hives
Bowel troubles
Shortness of breath
Swollen glands
Convulsions or fits
17. Does this child have a good urinary stream? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
NO
YES
18. Other illnesses or diseases? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
If yes, what? ________________________________________________________
19. Has this child ever been hospitalized? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
If yes, for what? ____________________________________________________
20. Has this child had any serious accidents? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
If yes, what? ________________________________________________________
21. Does this child have any physical restrictions? If yes, what? . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
If yes, what?___________________________________________________________
22. Has this child ever been seen by a medical specialist? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
If yes, who7___________________________________________________________
C. GROWTH & DEVELOPMENT
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3. Did this child say any words by the time he/she was 1-1/2 years old? . . . . . . . . . . . . . . . . . . . . .
NO
YES
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5. Does this child ask questions beginning with what, how, where, when, who? . . . . . . . . . . . . .
NO
YES
6. Does this child ever say he/she feels sad, bad, mad, happy, glad?. . . . . . . . . . . . . . . . . . . . . . . .
NO
YES
7. How does this child treat or get along with:
FATHER?____________________________________ MOTHER? ____________________________________
BROTHERS?__________________________________ SISTERS?______________________________________
OTHER CHILDREN? ________________________________________________________________________
__________________________________________________________________________________________
8. Has this child had any school experience such as Sunday School, Nursery School,
Head Start, Dancing, Gymnastics, etc? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
NO
YES
If yes, does he do as well as the other children in his/her class? . . . . . . . . . . . . . . . . . . . . .
NO
YES
9. What things does this child like to do for fun?______________________________________________________
__________________________________________________________________________________________
10. What activities does this child do particularly well? __________________________________________________
__________________________________________________________________________________________
11. With what household tasks does this child help? ____________________________________________________
__________________________________________________________________________________________
12. What new things have you noticed this child doing within the last six months?____________________________
__________________________________________________________________________________________
13. Is there anything additional that you would like to tell us about your child? ______________________________
__________________________________________________________________________________________
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