Detailed Health Assessment Record

Name:

Date of Birth:

Age:

Gender:

Parent/Guardian Name:

Contact Number:

Assessment Date:

Any history of chronic illness?

Known allergies?

Current medications?

Past surgeries or hospitalizations?

Family history of illness?

Height:

Weight:

Body Mass Index (BMI):

Vision Screening:

Hearing Screening:

Skin Condition:

Dental Health:

Respiratory Rate (breaths/min):

Heart Rate (beats/min):

Blood Pressure:

Gross Motor Skills:

Fine Motor Skills:

Speech and Language:

Social Interaction:

MMR (Measles, Mumps, Rubella)

DTaP (Diphtheria, Tetanus, Pertussis)

Polio

Varicella

Hepatitis B

Emotional Regulation:

Attention Span:

Sleep Patterns:

Appetite:

Physical Health

Developmental Milestones

Immunizations

Emotional and Behavioral Health