LIC 702 Preadmission Health History


State of California – Health and Human Services Agency California Department of Social Services
LIC 702 (10/19) (CONFIDENTIAL)

CHILD’S PREADMISSION HEALTH HISTORY - PARENT/AUTHORIZED REPRESENTATIVE REPORT

 

CHILD’S NAME

SEX

BIRTHDATE

PARENT / AUTHORIZED REPRESENTATIVE NAME

DOES PARENT / AUTHORIZED REPRESENTATIVE LIVE IN HOME WITH CHILD?

PARENT / AUTHORIZED REPRESENTATIVE NAME

DOES PARENT / AUTHORIZED REPRESENTATIVE LIVE IN HOME WITH CHILD?

IS / HAS CHILD BEEN UNDER REGULAR SUPERVISION OF PHYSICIAN?

DATE OF LAST PHYSICAL/ MEDICAL EXAMINATION


DEVELOPMENTAL HISTORY

(*For infants and preschool-age children only)

WALKED AT* MONTHS
TOILET TRAINING STARTED AT* MONTHS
BEGAN TALKING AT* MONTHS

 


PAST ILLNESSES

Check illnesses that child has had and specify approximate dates of illnesses:

…   DATES
Chicken Pox
…Asthma
…Rheumatic Fever
…Hay Fever
Diabetes
Epilepsy
Whooping Cough
Mumps
Poliomyelitis
Ten-Day Measles
(Rubeola)
Three-Day Measles
(Rubella)

SPECIFY ANY OTHER SERIOUS OR SEVERE ILLNESSES OR ACCIDENTS

DOES CHILD HAVE FREQUENT COLDS?

HOW MANY IN LAST YEAR?

LIST ANY ALLERGIES STAFF SHOULD BE AWARE OF

 


DAILY ROUTINES

(*For infants and preschool-age children only)

WHAT TIME DOES CHILD GET UP?*

WHAT TIME DOES CHILD GO TO BED?*

DOES CHILD SLEEP WELL?*

DOES CHILD SLEEP DURING THE DAY?*

WHEN?*

HOW LONG?*

 

 

DIET PATTERN: (What does child usually eat for these meals?)

BREAKFAST

LUNCH

DINNER

WHAT ARE USUAL EATING HOURS?

BREAKFAST

LUNCH

DINNER

ANY FOOD DISLIKES?

ANY EATING PROBLEMS?

 

IS CHILD TOILET TRAINED?*

IF YES, AT WHAT STAGE:*

ARE BOWEL MOVEMENTS REGULAR?*

WHAT IS USUAL TIME?*

WORD USED FOR “BOWEL MOVEMENT”*

WORD USED FOR URINATION*

 

PARENT / AUTHORIZED REPRESENTATIVE EVALUATION OF CHILD’S HEALTH

IS CHILD PRESENTLY UNDER A DOCTOR’S CARE?

IF YES, NAME OF DOCTOR:

DOES CHILD TAKE PRESCRIBED MEDICATION(S)?

IF YES, WHAT KIND AND ANY SIDE EFFECTS:

DOES CHILD USE ANY SPECIAL DEVICE(S):

IF YES, WHAT KIND:

DOES CHILD USE ANY SPECIAL DEVICE(S) AT HOME?

IF YES, WHAT KIND:

 

PARENT/ AUTHORIZED REPRESENTATIVE EVALUATION OF CHILD’S PERSONALITY

HOW DOES CHILD GET ALONG WITH PARENT / AUTHORIZED REPRESENTATIVE, BROTHERS, SISTERS AND OTHER CHILDREN?

HAS THE CHILD HAD GROUP PLAY EXPERIENCES?

DOES THE CHILD HAVE ANY SPECIAL PROBLEMS/FEARS/NEEDS? (EXPLAIN.)

WHAT IS THE PLAN FOR CARE WHEN THE CHILD IS ILL?

REASON FOR REQUESTING DAY CARE PLACEMENT

 

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Signed by Kathy Olvera
Signed On: January 27, 2021

Signature Certificate
Document name: LIC 702 Preadmission Health History
lock iconUnique Document ID: 3e3e79043efcbd05845af6dd01974654855eca35
Timestamp Audit
January 7, 2021 6:09 pm PSTLIC 702 Preadmission Health History Uploaded by Kathy Olvera - info@techniquegym.com IP 192.163.242.93