Health History Update
Macomb Community Action Head Start 0-5
Health History Update
Child’s Name (last, first)
Date of Birth
/
Month
/
Day
Year
Date
Does your child participate in WIC?
Yes?
No?
What health insurance does your child have
What dental insurance does your child have
Child’s Doctor
Phone #
Office Name
City
Are
there
ANY
HEALTH
concerns
your child’s teacher should
be
aware
of
(examples
include
asthma, seizures, eczema
Yes
No
If YES, please explain:
Does your child have any Doctor Diagnosed Food Allergies?
Yes
No
If YES, please explain:
Will your child require any medication in the classroom:
Yes
No
If YES, please explain:
Current Dental Information:
Dentist Name
Phone #
Office Name
CIty
Parent Name
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