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State of Connecticut Department of Education

Early Childhood Health Assessment Record (For children ages birth – 5)

To Parent or Guardian: In order to provide the best experience, early childhood providers must understand your child’s health needs. This form

requests information from you (Part I) which will be helpful to the health care provider when he or she completes the health evaluation (Part II). State

law requires complete primary immunizations and a health assessment by a physician, an advanced practice registered nurse, a physician assistant, or a

legally qualified practitioner of medicine, an advanced practice registered nurse or a physician assistant stationed at any military base prior to entering

an early childhood program in Connecticut.

Please print

Address (Street, Town and ZIP code)

Health Insurance Company/Number* or Medicaid/Number*

Does your child have health insurance? Does your child have dental insurance? Does your child have HUSKY insurance?

Y Y Y

N N N

If your child does not have health insurance, call 1-877-CT-HUSKY

* If applicable

Part I — To be completed by parent/guardian.

Please answer these health history questions about your child before the physical examination.

Please circle Y if “yes” or N if “no.” Explain all “yes” answers in the space provided below.

Explain all “yes” answers or provide any additional information:

Have you talked with your child’s primary health care provider about any of the above concerns? Y N

Please list any medications your child

will need to take during program hours:

All medications taken in child care programs require a separate Medication Authorization Form signed by an authorized prescriber and parent/guardian.

ED 191 REV. 8/2011 C.G.S. Section 10-16q, 10-206, 19a.79(a), 19a-87b(c); P.H. Code Section 19a-79-5a(a)(2), 19a-87b-10b(2)

I give my consent for my child’s health care provider and early

childhood provider or health/nurse consultant/coordinator to discuss

the information on this form for confidential use in meeting my

child’s health and educational needs in the early childhood program. Signature of Parent/Guardian Date

Any health concerns Y N Frequent ear infections Y N Asthma treatment Y N

Allergies to food, bee stings, insects Y N Any speech issues Y N Seizure Y N

Allergies to medication Y N Any problems with teeth Y N Diabetes Y N

Any other allergies Y N Has your child had a dental

examination in the last 6 months Y N

Any heart problems Y N

Any daily/ongoing medications Y N Emergency room visits Y N

Any problems with vision Y N Very high or low activity level Y N Any major illness or injury Y N

Uses contacts or glasses Y N Weight concerns Y N Any operations/surgeries Y N

Any hearing concerns Y N Problems breathing or coughing Y N Lead concerns/poisoning Y N

Developmental — Any concern about your child’s: Sleeping concerns Y N

1. Physical development Y N 5. Ability to communicate needs Y N High blood pressure Y N

2. Movement from one place

to another Y N

6. Interaction with others Y N Eating concerns Y N

7. Behavior Y N Toileting concerns Y N

3. Social development Y N 8. Ability to understand Y N Birth to 3 services Y N

4. Emotional development Y N 9. Ability to use their hands Y N Preschool Special Education Y N

Parent/Guardian Name (Last, First, Middle)

Home Phone Cell Phone

Early Childhood Program (Name and Phone Number)

Race/Ethnicity

❑ American Indian/Alaskan Native ❑ Hispanic/Latino

❑ Black, not of Hispanic origin ❑ Asian/Pacific Islander

❑ White, not of Hispanic origin ❑ Other

Primary Health Care Provider:

Name of Dentist:

Child’s Name (Last, First, Middle)

Birth Date (mm/dd/yyyy)

❑ Male ❑ Female

ED 191 REV. 8/2011 Part II — Medical Evaluation

Health Care Provider must complete and sign the medical evaluation, physical examination and immunization record.

Child’s Name Birth Date Date of Exam (mm/dd/yyyy) (mm/dd/yyyy) ❑ I have reviewed the health history information provided in Part I of this form

Physical Exam Note: *Mandated Screening/Test to be completed by provider.

*HT in/cm % *Weight lbs. oz / % BMI / % *HC in/cm % *Blood Pressure / (Birth – 24 months) (Annually at 3 – 5 years)

Screenings

screen between 25 – 72 months

❑ No ❑ Yes

*Developmental Assessment: (Birth – 5 years)

Results:

❑ No ❑ Yes Type:

*IMMUNIZATIONS ❑ Up to Date or ❑ Catch-up Schedule: MUST HAVE IMMUNIZATION RECORD ATTACHED

*Chronic Disease Assessment:

❑ No ❑ Yes: ❑ Intermittent ❑ Mild Persistent ❑ Moderate Persistent ❑ Severe Persistent ❑ Exercise induced Asthma

If yes, please provide a copy of an Asthma Action Plan

❑ Rescue medication required in child care setting: ❑ No ❑ Yes

❑ No ❑ Yes: Allergies

❑ No ❑ Yes Epi Pen required:

History/risk of Anaphylaxis: ❑ No ❑ Yes: ❑ Food ❑ Insects ❑ Latex ❑ Medication ❑ Unknown source If yes, please provide a copy of the Emergency Allergy Plan

Diabetes

Seizures

❑ No

❑ No

❑ Yes: ❑ Type I ❑ Type II Other Chronic Disease:

❑ Yes: Type:

❑ This child has the following problems which may adversely affect his or her educational experience: ❑ Vision ❑ Auditory ❑ Speech/Language ❑ Physical ❑ Emotional/Social ❑ Behavior

❑ This child has a developmental delay/disability that may require intervention at the program. ❑ This child has a special health care need which may require intervention at the program, e.g., special diet, long-term/ongoing/daily/emergency

medication, history of contagious disease. Specify:

❑ No ❑ Yes This child has a medical or emotional illness/disorder that now poses a risk to other children or affects his/her ability to participate

safely in the program.

Based on this comprehensive history and physical examination, this child has maintained his/her level of wellness.

This child may fully participate in the program.

This child may fully participate in the program with the following restrictions/adaptation: (Specify reason and restriction.)

❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes

❑ No ❑ Yes Is this the child’s medical home? ❑ I would like to discuss information in this report with the early childhood provider and/or nurse/health consultant/coordinator.

Signature of health care provider MD / DO / APRN / PA Date Signed Printed/Stamped Provider Name and Phone Number

*Vision Screening

❑ EPSDT Subjective Screen Completed

(Birth to 3 yrs)

❑ EPSDT Annually at 3 yrs (Early and Periodic Screening, Diagnosis and Treatment)

Type: Right Left

With glasses 20/ 20/

Without glasses 20/ 20/

❑ Unable to assess

❑ Referral made to:

*Hearing Screening

❑ EPSDT Subjective Screen Completed

(Birth to 4 yrs)

❑ EPSDT Annually at 4 yrs (Early and Periodic Screening,

Diagnosis and Treatment)

Type: Right Left

❑ Pass ❑ Pass

❑ Fail ❑ Fail

❑ Unable to assess

❑ Referral made to:

*Anemia: at 9 to 12 months and 2 years

*Hgb/Hct:

*Date

*Lead: at 1 and 2 years; if no result

Lead poisoning (≥ 10ug/dL)

*Result/Level: *Date

*TB: High-risk group? ❑ No ❑ Yes

Test done: ❑ No ❑ Yes Date:

Results:

Treatment:

*Dental Concerns ❑ No ❑ Yes

❑ Referral made to:

Has this child received dental care

in the last 6 months? ❑ No ❑ Yes

Other:

Child’s Name: Birth Date: REV. 8/2011

Immunization Record To the Health Care Provider: Please complete and initial below.

Vaccine (Month/Day/Year)

Immunization Requirements for Connecticut Day Care, Family Day Care and Group Day Care Homes

(36-59 mos.)

birthday1

or prior history

1st birthday

6 months apart5

1. Laboratory confirmed immunity also acceptable

2. Physician diagnosis of disease

3. A complete primary series is 2 doses of PRP-OMP (PedvaxHIB) or 3 doses of HbOC (ActHib or Pentacel)

4. As a final booster dose if the child completed the primary series before age 12 months. Children who receive the first dose of Hib on or after 12 months of age and before 15 months of age are

required to have 2 doses. Children who received the first dose of Hib vaccine on or after 15 months of age are required to have only one dose

5. Hepatitis A is required for all children born after January 1, 2009

6. Two doses in the same flu season are required for children who have not previously received an influenza vaccination, with a single dose required during subsequent seasons

Initial/Signature of health care provider MD / DO / APRN / PA Date Signed Printed/Stamped Provider Name and Phone Number

Vaccines Under 2

months of age

By 3

months of age

By 5

months of age

By 7

months of age

By 16

months of age

16–18

months of age

By 19

months of age

2-3 years of age

(24-35 mos.)

3-5 years of age

DTP/DTaP/

DT

None

1 dose

2 doses

3 doses

3 doses

3 doses

4 doses

4 doses

4 doses

Polio

None

1 dose

2 doses

2 doses

2 doses

2 doses

3 doses

3 doses

3 doses

MMR

None

None

None

None 1 dose after 1st

birthday1

1 dose after 1st

birthday1

1 dose after 1st

birthday1

1 dose after 1st

birthday1

1 dose after 1st

Hep B

None

1 dose

2 doses

2 doses

2 doses

2 doses

3 doses

3 doses

3 doses

HIB

None

1 dose

2 doses

2 or 3 doses

depending on

vaccine given3

1 booster dose

after 1st

birthday4

1 booster dose

after 1st

birthday4

1 booster dose

after 1st

birthday4

1 booster dose

after 1st

birthday4

1 booster dose

after 1st

birthday4

Varicella

None

None

None

None

None

None

1 dose after

1st birthday or

prior history of

disease1,2

1 dose after

1st birthday or

prior history of

disease1,2

1 dose after

1st birthday

of disease1,2

Pneumococcal

Conjugate

Vaccine (PCV)

None

1 dose

2 doses

3 doses

1 dose after

1st birthday

1 dose after

1st birthday

1 dose after

1st birthday

1 dose after

1st birthday

1 dose after

Hepatitis A

None

None

None

None 1 dose after

1st birthday5

1 dose after

1st birthday5

1 dose after

1st birthday5

2 doses given

6 months apart5

2 doses given

Influenza

None

None

1 or 2 doses

1 or 2 doses

1 or 2 doses6

1 or 2 doses6

1 or 2 doses6

1 or 2 doses6

1 or 2 doses6

Disease history for varicella (chickenpox)

(Date) (Confirmed by)

Exemption: Religious Medical: Permanent †Temporary Date

†Recertify Date †Recertify Date †Recertify Date

Dose 1 Dose 2 Dose 3 Dose 4 Dose 5 Dose 6

DTP/DTaP/DT

IPV/OPV

MMR

Measles

Mumps

Rubella

Hib

Hepatitis A

Hepatitis B

Varicella

PCV* vaccine *Pneumococcal conjugate vaccine

Rotavirus

MCV** **Meningococcal conjugate vaccine

Flu

Other

  

  

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ACTION FOR BRIDGEPORT COMMUNITY DEVELOPMENT

1070 PARK AVE BRIDGEPORT, CT

www.abcd.org

The mission of ABCD’s Early

Learning Division is to

empower families so that they

may overcome the impact of

poverty and improve the

quality of life for all family

members. To that end, ABCD

is committed to a comprehensive

program consisting of:

Family & Child Services for all family members

Inclusive of parents in the implementation & development of programs and policies

Advocacy and support for families and children

An enhanced collaboration between and among family & child services agencies to improve the knowledge and responsiveness of these agencies to the needs of children and their families

The fulfillment of this mission will create a collaborative consisting of parent, agency, and community of opportunity for all families and their children.

 a   b     c 

d ABCD / INNER CITY CHILDREN’S CENTER 1070 Park Ave Bridgeport, CT

203-366-8241-X 273

LUCILLE E. JOHNSON CENTER 816 Fairfield Ave Bridgeport, CT

203-331-4541

ABCD at HOLY NAME OF JESUS CENTER 1950 Barnum Ave Stratford, CT

203-385-1127

ABCD at GEORGE E. PIPKIN CENTER 52 George Pipkins Way Bridgeport, CT

203-576-9960 x 231

CESAR BATALLA CTR 927 Grand Street Bridgeport, CT

203-336-2153

TENDER LOVING CARE: THERAPEUTIC PRO-GRAM (TLCC) ABCD 1070 Park Ave Bridgeport, CT

203-366-8241 x 244

BULLS HEAD HOLLOW HEADSTART 108 Sanford Ave Bridgeport, CT

203-338-9640

JAMIE A. HULLEY CTR 460 Lafayette St Bridgeport, CT

203-367-6801

TRUMBULL GARDENS CENTER 715 Trumbull Ave Bridgeport, CT

203-371-5117

WEST END CENTER 361 Bird Street Bridgeport, CT

203-335-0553

CHARLES B TISDALE CENTER 1795 Stratford Ave Bridgeport, CT

203-330-0166

FULL & PART YEAR TRUMBULL / MONROE REGIONAL HEAD START 240 Middlebrooks Ave Trumbull, CT

203-452-4423

PART DAY/PART YEAR: BULLARDS HAVEN 500 Palisade Ave Bridgeport, CT

203-579-6333 x 6611

PART DAY/PART YEAR: ABCD at STRATFORD SOUTHEND COMMUNITY CTR 19 Bates Street Stratford, CT 203-377-4721

The first five years of childhood are the most important in development and learning. Our educational curriculum is designed to help children reach their fullest potential.

At ABCD we have set the standard for the highest quality of preschool programs in the Greater Bridgeport area. Our programs feature fun, age-appropriate lessons and activities which help develop the whole child: physically, intellectually, emotionally and socially. Each child is encouraged to explore and discover at his or her own pace.

Not only do we provide services for the children, we also help families with their needs. Our social service team is ready to assist families with referrals to community agencies or other ABCD programs.

Most families qualify for our sliding scale fee or free programs.

Our curriculum has been developed in accordance with CT Department of Education Early Learning standards as well as the Head Start’s Creative Curriculum program with the goal of School Readiness.

In addition our Early Head Start Home Based program option supports children and their families through home visits and group socialization experiences.

ABCD welcomes all children. We greatly appreciate the cultures of all our families and staff and provide a multicultural environment. We assist in providing translation services. Our qualified staff are also trained for children with disabilities. With on-site support from mental health, education and disabilities specialists all children are assured to receive the required services. Assistance with referrals for children are also available.

We provide free nutritional meals daily. The meals are planned by the staff nutritionist with the parents, staff, and the caterer. We also have health professionals on staff who assist with children’s health concerns at the centers.

We have an open door policy and parents are always welcome. Parents have the opportunity to volunteer in their child’s classroom and also become active members of many different parent groups.