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GENERAL HEALTH APPRAISAL FORM
PARENT please complete AND SIGN
Child’s Name:_______________________________________________________
Birthdate: _____________________
Allergies: None or Describe___________________________________________________________________________________________
Type of Reaction ____________________________________________________________________________________________________
Diet:
Breast Fed
Formula _______________________
Age Appropriate
Special Diet ________________________________________________________________________________________________
Sleep: Your health care provider recommends that all infants less than 1 year of age be placed on their back for sleep.
Preventive creams/ointments/sunscreen may be applied as requested in writing by parent unless skin is broken or bleeding.
I, ________________________________________ give consent for my child’s care health provider, school child care or camp personnel to
discuss my child’s health concerns. My child’s health provider may fax this form (& applicable attachments) to my child’s school, child care
or camp personnel. FAX #: _____________________________ DATE: _____________________________
Parent/Guardian Signature___________________________________________________________________
HEALTH CARE PROVIDER: Please Complete After Parent Section Completed
Date of Last Health Appraisal: _____________________________
Weight @ Exam: _______________________________________
Physical Exam:
Normal
Abnormal (Specify any physical abnormalities)_____________________________________________________
Allergies: None or Describe__________________________ Type of Reaction __________________________________________________
6LJQLÀFDQW+HDOWK&RQFHUQV Severe Allergies Reactive Airway Disease Asthma Seizures Diabetes Hospitalizations
Developmental Delays Behavior Concerns Vision Hearing Dental Nutrition Other ________________________________
Explain above concern (if necessary, include instructions to care providers): ______________________________________________________
Current Medications/Special Diet: None or Describe ______________________________________________________________________
Separate medication authorization form is required for medications given in school, child care or camp
For Fever Reducer or Pain Reliever (for 3 consecutive days without additional medical authorization) PLEASE CHOOSE ONE PRODUCT
Acetaminophen (Tylenol) may be given for pain or fever over 102 degrees every 4 hours as needed
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OR Ibuprofen (Motrin, Advil) may be given for pain or for fever over 102 degrees every 6 hours as needed
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Immunizations: Up-to-Date See attached immunization record Administered today: _____________________________________________
Health Care Provider: Complete if Appropriate
**ONLY REQUIRED BY EARLY HEAD START AND HEAD START PROGRAMS PER STATE EPSDT SCHEDULE**
** Height @ Exam _____ ** B/P _____ **Head Circumference (up to 12 months) _______ **
** HCT/HGB _____ ** Lead Level
Not at risk or Level _____
**TB
Not at risk or Test Results Normal Abnormal
**Screenings Performed:
Vision: Normal Abnormal
Hearing: Normal Abnormal
Dental: Normal Abnormal-
Recommended Follow-up________________________________________________________________________________________
Provider Signature
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Next Well Visit: Per AAP guidelines* or Age__________
This child is healthy and may participate in all routine activities in school sports, child care or camp SURJUDP$Q\FRQFHUQVRUH[FHSWLRQVDUHLGHQWLÀHGRQWKLVIRUP
_____________________________________________________
Signature of Health Care Provider (certifying form was reviewed) Date: _______________
The Colorado Chapter of the American Academy of Pediatrics (AAP) and Healthy Child Care Colorado have approved this form. 04/07*The AAP recommends that children from 0-12 years have health appraisal visits at: 2, 4, 6, 9, 12, 15, 18 and 24 months, and age 3, 4, 5, 6, 8, 10 and 12 years.
Copyright 2007 Colorado Chapter of the American Academy of Pediatrics
Source: http://www.ckcs.net/preschool-images/info_copy/health_form2012.pdf
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CONCURSO DE BAILE ESTUDIANTIL 2009 CONVOCATORIA DE LOS PARTICIPANTES 1. Podrán participar alumnos (as) entre 13 y 18 años de edad quienes deberá integrar grupos de un mínimo de 6 y máximo de 15 participantes; los grupos podrán ser mixtos o de un solo sexo. en dos categorías: 2. Cada grupo deberá representar una coreografía libre con una duración mínima de 3:00 minuto