PTIONS Full-day Preschool

Transcripción

Physical Exam
To be completed by a doctor - must be current (within 1 year before starting school) and must be renewed yearly.
Child's Name:_____________________________________________________ DOB:___________________________
Sex: M
F
I authorize my child's health information to be released to Options Full-day Preschool.
Parent/Guardian Signature:__________________________________________________ Phone: ___________________________________
Please complete all sections as required according to the State of California EPSDT schedule.
If unable to screen, write a reason and do not leave blank.
A. Insurance
B. Physical Exam
 Medi-Cal
 Healthy Families
 Private Insurance
 None
Normal
Abnormal
F. Screenings (1 to 7) - Do not leave blank. Check all applicable boxes.
No Concern
Explain in G
1. Blood Pressure: Normal High Low
Date:_______________________
General Appearance
2. Growth Assessment:
Head-eyes/ears/nose/mouth
Arms/Legs
Muscles/Bones
Wt:_______________
BMI:______________
BMI%:____________
Normal
Abnormal
Heart
Date:_______________________
Lungs
Hearing aid needed? Yes No
4. Vision Screening:
Normal
H
V
Result:______________________
Corrective Lenses Needed? Yes No
Lymph nodes
5. Hemoglobin (Hgb/Hct): Normal High Low
Hormones
Genitals
Date:_______________________
Urinary
Anemia? Yes No
C. Assessment &
Risk Exposure
GA
Result:______________________
Abnormal
Date:_______________________
Nerves
Result:______________________
Date:______________ Ht:_______________
3. Hearing Screening:
Stomach/GI
BP
Normal Overweight Underweight
Skin
Office
Normal
Abnormal
No Concern
Explain in G
Lead
Normal High
1st Date:____________________
Health History
Result:______________________
6. Blood Lead Test: Must have 1 on or after 24 months of age
1st Lead:
Hgb
1st Result: __________________
High lead level? Yes No
Dental Assessment
Nutritional Assessment
2nd Lead:
L-risk
Normal High
Developmental Assessment
2nd Date:___________________
Speech
High lead level? Yes No
2nd Result: _________________
7. Tuberculosis Clearance:  Risk factors not present.
Behavioral / Psychosocial
Tobacco Exposure Risk
Tuberculin Test:
Chest X-Ray, if Tb test is positive:
Tb Exposure Risk
Negative Positive N/A
Normal Abnormal N/A
Lead Exposure Risk
Date Given:__________________
Date: _______________________
Date Read:__________________
Result:______________________
D. Anticipatory
Guidance Given?
 Yes
E. Allergies?
 Yes
 No
Result: _____________________
 No
Tb
Cxr
Tx
Treatment & Date:_________________________________________
If yes, list:
G. Concern (list conditions and any treatment/information given)
Physician's Information (May be written or stamped)
Physician's Name/Office:
______________________________________________
Address:
______________________________________________
Phone:
______________________________________________
Physician's Signature:
______________________________________________
Date: _________________________________________
Date of Exam: __________________________
Rev 5/14
ptions Full-day Preschool
Emergency & Identification Information
Información para Emergencia e Identificación
Nombre del Nino(a) ______________________________________
M
Fecha de Nacimiento ________________________  F
Parent/Guardian Name
Home Phone
Padre / Tutor Nombre _____________________________________
Teléfono de la Casa (________)________________________
Address
Work Phone
Child’s Name
Date of Birth
Unit
Dirección _______________________________ Unidad ______ Teléfono del Trabajo (________)________________________
City
Cell Phone
Ciudad _________________________________________________
Teléfono Celular (________)___________________________
Email_______________________________________________________________________________________________________
Additional persons over 18 years of age who may be called in an emergency and are authorized to remove child from the facility:
Personas adicionales que sean mayores de 18 años, que puedan ser llamados en caso de emergencia y
sean autorizados en recoger al niño/a de la escuela:
Name
Relation to Child
Home Phone
Work Phone
Cell Phone
Nombre
Relación al niño/a
Teléfono de la Casa
Teléfono del Trabajo
Teléfono Celular
Parent / Guardian
Padre / Tutor
 Grand Parent Abuelito(a)
 Uncle/Aunt - Tío/Tía
 Friend - Amigo(a)
 None
Health Insurance
A Seguranza Medica________________________________________________ID # ___________________________________
Doctor Name
City
Phone
Nombre del Doctor __________________________________ Ciudad ______________________ Teléfono _____________________
Dentist Name
City
Phone
Nombre del Dentista _________________________________ Ciudad ______________________ Teléfono _____________________
List all health concerns
Mencione todo problema de salud________________________________________________________________________________
List all medications
List all allergies
Mencione todo medicamento__________________________________ Mencione todo tipo de alergias _________________________
_____ As the legal parent/guardian, I hereby give consent to
Options Full-day Preschool to obtain all emergency medical or
dental care, at my expense, prescribed by a duly licensed
Physician (MD), Osteopath (DO) or Dentist (DDS) for my child
named above. This care may be given under whatever
conditions are necessary to preserve the life, limb or well being of
my child.
______ Como padre/guardián legal, yo autorizo a Options Full-day
Preschool a obtener todo tipo de cuidado médico o dental en caso
de emergencia, bajo mi responsabilidad económica, recetado por
un Medico, Osteópata o Dentista con debida licencia para mi hijo/a
mencionado arriba. Este cuidado puede ser proporcionado bajo
cualquier circumstancia que sea necesaria para conservar la vida,
miembro, o el bienestar de mi hijo.
Signature
Date
Firma ____________________________________________________ Fecha ______________________________
white – emergency binder
yellow – office file
pink – site file
Rev 05-14
OPTIONS – A CHILD CARE AND HUMAN SERVICES AGENCY
CHILD ATTENDANCE POLICY
ATTENDANCE POLICY in accordance with the California Department of Education,
Child Development Division.
The number of spaces for children in all of our programs are limited, it is important that families who are
receiving care are those that need it and will utilize it appropriately.
A. Excused Absences
There are days when your child will not be in care due to:
1. Child is ill
2. Parent is ill
3. Court ordered visitation (with documentation)
4. Family Emergency
5. “Child Best Interest” days (for example: vacation, visiting relatives or days home with parent – other
than illness). Note: CDD allows only 10 “Child Best Interest” days per child per contract year to be
counted as excused.
If your child has been out for any of these reasons, when you return to care you must indicate in writing the
specific cause with a full signature. For example: “John had the flu”, or “John was visiting grandparents”.
B. Unexcused Absences
Any absences other than the 5 listed above are unexcused.
C. Termination
Options may terminate a family due to attendance problems for the following reasons:
1. Excessive unexcused absences
2. Excessive late drop offs/pick ups compared to contracted hours (CDC, SC and CCS Divisions or class
hours SP Division)
3. Late pick ups after scheduled staff hours
I have carefully read and completely understand the above stated policy.
Parent Name: __________________________
Parent Signature: ___________________________
please print
Child Name: ___________________________
Date: __________________
Board Approved 5/04
Child’s Name ______________________________
Photographs/Field Trips/DSS-CCL
Fotografías/Paseos/DSS-CCL
Parent/Guardian Name ________________________________
Photographs and Video
_____ I give permission for photographs and or video to be taken of my child engaged in regular program activities. I
understand that these may be used as part of program outreach activities including advertising, displays, parent
handbook, program brochure, Options web-site, news stories, or any other deemed appropriate by Options staff.
Field Trips
_____ I give permission for my child to attend walking field trips that are provided by Options Full-day Preschool. I
understand that throughout the year walking field trips may be taken to various locations in close proximity to my
child’s school. When the class is planning a walking field trip, the date, location, departure time, expected time of
arrival and the route that will be taken will be posted for review. (A separate permission slip will be issued for field
trips that require bus transportation.)
Department of Social Services - Community Care Licensing Rights
_____ I understand that the child care facility that my child attends is required to meet the licensing regulations of the
Department of Social Services (DSS) – Community Care Licensing. Therefore, I recognize that the DSS has the
authority to inspect the file that Options maintains for my child. The file contains the application for service, health
history, emergency care information and all other documents used to establish eligibility for the program.
_____ I understand that the Department of Social Services has the authority to observe the physical condition of my
child, including conditions which could indicate abuse or neglect and to have a licensed medical professional
examine my child.
Signature _________________________________________________ Date _________________________________
******************************************************************************************************************************************
Nombre del Niño(a) ______________________________ Nombre de Padre/Tutor ________________________________
Fotografías y Video
_____ Yo doy permiso para fotografiar y / o video, tomado de mi hijo(a) durante las actividades del programa. Entiendo que estos
pueden ser utilizados como parte del programa y actividades de difusión, incluida la publicidad, muestras, manual para los
padres, folleto del programa, página-web de Options, noticias, o de cualquier otra índole que sea apropiada por el personal de
Options.
Paseos de campo/Excursiones
_____ Yo doy permiso para que mi hijo(a) asista a paseos de campo/excursiones que se proporcionan por Options, Full-day
Preschool. Yo entiendo que durante todo el año paseos de campo/ excursiones se llevaran a cavo en distintas ubicaciones en
las proximidades de la escuela de mi hijo(a). Tenga en mente cuando un paseo/excursión se planee, la fecha, lugar, hora de
salida, hora prevista de llegada y la ruta que sea, se publicara para su revisión. (Un permiso se expedirá por separado para
los paseos/excursiones que requieren el transporte en autobús).
Departamento de Servicios Sociales – Derechos de Licencia para el Cuidado de la Comunidad
_____ Yo entiendo que el centro de cuidado infantil que mi hijo(a) asiste requiere que mantenga y cumpla las normas de concesión
de licencias del Departamento de Servicios Sociales (DSS) - Licencia de Cuidado Comunitario. Por lo tanto, reconozco que el
DSS tiene la autoridad para examinar el expediente que mantiene Options de mi hijo(a). El expediente contiene la solicitud de
servicio, el historial médico, información sobre el cuidado de emergencia y todos los demás documentos utilizados para
establecer la elegibilidad del programa.
_____ Yo entiendo que el Departamento de Servicios Sociales tiene la autoridad para observar la condición física de mi hijo(a),
incluidas las condiciones que podrían indicar abuso o negligencia y tener una licencia médica profesional examinar a mi
hijo(a).
Firma _____________________________________________________ Fecha _________________________________
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Family History
Historia Familiar
Child’s Name__________________________________________ Birth Place _________________________
Nombre del Niño/a
Lugar de Nacimiento
Mother
Madre
Name____________________________________ Birth Date_______________
Nombre
Fecha de Nacimiento
Primary Language _________________________ Working _________ School___________
Idioma Principal
Trabajo
Escuela
Father
Padre
Name____________________________________ Birth Date_______________
Nombre
Fecha de Nacimiento
Primary Language _________________________ Working _________ School___________
Idioma Principal
Trabajo
Escuela
Siblings
Hermanos
Name / Nombre
Age / Edad
1) _____________________________________________
_________
2) _____________________________________________
_________
3) _____________________________________________
_________
4) _____________________________________________
_________
5) _____________________________________________
_________
Present Family Situation / Situación Familiar Presente
1. Present home/ Su hogar presente es
Apt./ Apto.
_____ House/Casa _____
Other/ Otro _____
2. How long has the child lived in present home? ____________________
¿Hace cuanto tiempo que el niño/a vive en el presente hogar?
3. Parents:
Padres
Living Together ____ Separated ___Divorced ____ Parent ill ____ Deceased _____
Viven Juntos
Separados
Divorciados
Padre enfermo Muerto
4. Age of child at time of above change in family situation _________________
Edad del niño/a en el tiempo que hubo cambios en la situación familiar
5. If parents are divorced or separated, does child see absent parent? _______
¿Si los padres son divorciados o separados, el niño/a visita al padre ausente?
How often?________
Seguido?
6. What helpful information can you offer about how the absence of a parent has been worked out with your
child and what has been noted about his/her reaction to these circumstances?
¿Hay información que nos pueda ofrecer para ayudarnos a saber cómo ha afectado a su niño/a y ue ha
notado acerca de la reacción en estas circunstancias?
_____________________________________________________________________________________
7. Who cares for your child at home during the parent’s absence? __________________________________
¿Quien se hace cargo del niño/a en casa durante la ausencia de los padres?
8.
1
Age of child when mother first went to work/school? __________________________________________
¿Cuál era la edad del niño/a cuando la madre fue por primera vez a trabajar/escuela?
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rev 5-14
Family History/Historia Familiar
Child’s Behavior / Comportamiento del Niño/a
9. Does the child nap?  Yes/Si  No
¿El niño/a duerme al medio día?
If yes, during what hours? ________________
¿Durante que horas?
10. What time does the child wake up in the morning? _____________
¿Cauno despierta?
When is bedtime? _____________
¿A la hora de dormir en la noche?
11. Does the child wet the bed when sleeping? ¿Se orina la cama?
 Yes/Si
 No
12. Does the child have occasional potty accidents during the day?
 Yes/Si
¿Durante el día tiene ocasionalmente el niño/a accidentes de baño?
 No
13. Does the child feed his/her self?  Yes/Si  No
¿Come solo?
14. Does the child drink a bottle?  Yes/Si  No
¿Toma botella?
15. With whom does child usually play? _______________________________________________________
¿Con quién juega regularmente el niño/a?
16. What methods of discipline have proved most effective for you? _________________________________
¿Que método de disciplina le ha sido más efectivo para usted?
17. What about your child makes you most proud and happy? ______________________________________
¿Qué es lo que hace que su hijo/a se sienta más orgulloso y contento?
18. In what way do you think your child needs help? ______________________________________________
¿De qué manera piensa usted que su hijo necesita más ayuda?
19. What type of situations are most upsetting to the child? ________________________________________
¿Qué tipos de situaciones hacen que su hijo/a se enoje?
20. What does your child do when he/she is upset? ______________________________________________
¿Qué hace su hijo/a cuando se enoja?
21. What comforts your child most at these times? _______________________________________________
¿Qué es lo que le mas consola a su hijo/a en esos momentos?
22. What is your child fearful of? _____________________________________________________________
¿Qué es lo que más le da miedo?
23. What major experiences or adjustments have been difficult for your child? _________________________
¿Cuáles son las experiencias o cambios que le han sido más difíciles para su hijo/a?
_____________________________________________________________________________________
24. What additional comments can you make to help us get to know your child better? ___________________
¿Qué comentarios adicionales pudiera darnos para conocer a su hijo/a mejor?
_____________________________________________________________________________________
_____________________________________________________________________________________
Signature of Parent/Guardian __________________________________________ Date _________________
Firma del Padre y/o guardián
Fecha
Signature of Staff Person Reviewing Form ____________________________________ Date _____________
Miembro del Personal
Fecha
2
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Health History / Historial de Salud
Child’s Name: Last, First, MI / Apellido y Nombre del Niño
Sex / Sexo
M 
Site / Escuela
Birthdate / Fecha de Nacimiento
F
 Foster/Guardianship-Do not know health history
Month_______ Day______ Year_______
Mes
Día
Año
Niño de crianza /Tutor-Historial de salud desconocido
1. Obstetrical & Neonatal History / Historia Obstétrico & Neonatal
Complications of Pregnancy: (If "Yes" specify)
Complicaciones de embarazo: (Si especifique)
No/No
Did mother receive prenatal care?
(Cuidado Prenatal)
 Yes/Sí
Pregnancy Duration/Duración de Embarazo
Months/Meses_______
 Yes/Si  No
Delivery Method: (Método de parto)
Labor Hours/Horas en Parto__________
Newborn Condition/Complication
Condición del recién nacido o Complicaciones
 Vaginal  Cesarean/ Por cesárea
Birth weight/Peso de recién nacido:
_____________ lbs ____________oz
(Kilos multiplied by 2.205 equals to lbs.)
2. Child’s Developmental History (Give age and comment as necessary)
Historia del Desarrollo (De la edad de cada etapa de desarrollo en que ocurrió y proporcione comentario apropiado)
STAGE OF DEVELOPMENT/
ETAPA DE DESARROLLO
Sat up without help/
Sentarse sin ayuda
Crawled/Gateo
AGE
EDAD
COMMENT/
COMENTARIOS
STAGE OF DEVELOPMENT/
ETAPA DE DESARROLLO
Fed self/Comió solo
AGE
EDAD
COMMENTS/
COMENTARIOS
First word/Primera palabra
Walked/Camino
Sentences/Oraciones
Toilet trained/Va solo al baño
Other/Otro
3. Child’s Medical History (Place “X” in column) Historia Médica del niño y enfermedades (marque con “X” en la columna que aplique):
ILLNESS
Yes-Explain
ILLNESS
Yes-Explain
ILLNESS
Yes-Explain
NO
NO
NO
Enfermedades
Si-Explique
Enfermedades
Si-Explique
Enfermedades
Si-Explique
Abdominal pains
Fatigues easily
Nose bleeds
Dolor abdominal
Se fatiga
Sangrado de nariz
Allergies to food
Frequent colds
Pneumonia
Alergias a comida
Resfrios frecuentes
Neumonía
Allergies to medication
Frequent headache
Red measles
Alergias a medicamentos
Dolor de cabeza
Sarampión
frecuente
Allergies to environnment
Frequent sore throat
Rubella
Alergia al ambiente
Dolor de garganta
Rubéola
Anemia
Seizures
Asimentos
Severe skin rash
Sarpullido severo
Bedwetting
Orina la cama
Head injury
Lesión a la cabeza
Hearing / difficulty
hearing
Dificultades para oír
Heart disease
Enfermedad del corazón
Blood disorder
Enfermedad de la sangre
Heart murmur
Soplo en el corazón
Surgeries
Cirugías
Broken bones
Quebraduras
High fevers
Fiebres altas
Speech problems
problemas del habla
Change of appetite
Cambio de apetito
Chicken pox
Varicela
Joint pain
Dolor en las coyunturas
Kidney disease
Enfermedad del riñón
Trouble chewing
Problemas para mascar
Trouble swallowing
Problemas para tragar
Dehydration
Deshidratación
Limp/gait problems
Problemas para andar
Tuberculosis
Tuberculosis
Diabetes
Diabetes
Meningitis
Meningitis
Vision problems/difficulty
seeing
Problemas de visión
Easily bruised
Moretones fácilmente
Mumps
Paperas
Whooping cough
Tos Ferina
Ear infection
Infección de oido
Night sweats
Suda de noche
Other
Otro
Asthma
Asma
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Célula de la hoz
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(2) Health History/Historial de Salud
Child’s Name/Nombre del Niño/: ___________________________________
4. List any current medication(s)/Apunte cualquier medicamento actual: _________________________________________________________________
5. Does the child currently (or is supposed) to wear glasses?
El niño/a actualmente usa o se supone que debe usar lentes?
6a. Number of adults in the household that smoke:
Numero de adultos en casa que fuman:
__________
 Yes/Si  No
6b. Does your child ride in a car with someone who smokes?
¿Su hijo(a) viaja en automobil con personas que fuman?
7. Immediate Family Medical History (“X” Applicable column and describe in designated space)
Historial Medico de Familia Cercana (marque con “X” en la columna que apliqué y describa)
YES: specify family
YES: specify family
ILLNESS
ILLNESS
NO
member
NO
member
Enfermedades
Enfermedades
SI: especifique quien
Anemia
Epilepsy
Epilepsia
Allergies
High blood Pressure
Alergias
Alta Presión Sanguine
Cancer
Jaundice
Cáncer
Ictericia
Diabetes
Kidney Disease
Diabetes
Enfermedad del Riñón
Bleeding Disorder
Heart Disease
Enfermedad de la
Enfermedad del
Sangre
Corazón
ILLNESS
Enfermedades
NO
 Yes/Si  No
YES: specify family
member
Mental Illness
Enfermedad Mental
Mental Retardation
Retraso Mental
Rheumatic Fever
Fiebre Reumática
Tuberculosis
Tuberculosis
Sickle cell Anemia
Anemia de la celula
Falciforme
8. Informed Consent for Screenings
Options Full-day Preschool utilizes screenings and assessments to ensure that your child receives the most appropriate instruction and care to
facilitate optimal growth, development and preparation to enter kindergarten. Options staff and contracted consultants review your child’s file and
consult with one another to gather all necessary information needed to make appropriate recommendations for your child’s health and education.
Options Full-day Preschool utiliza exámenes y evaluaciones para asegurar que su niño/a reciba la instrucción más adecuada y atención a facilitar un
óptimo desarrollo y preparación para entrar al Kindergarten. Personal de Options y los consultores contratados revisan los archivos de su niño/a y
consultaran entre ellos para formular las recomendaciones pertinentes para la salud y la educación de su hijo.
I authorize and consent to the following screening procedures for my child as long as he or she is enrolled in Options Full-day Preschool. I
understand that all screenings and observations are conducted by Options staff and/or Options contracted consultants. Parent/Guardian will be
informed if any concerns are noted or suspected. I understand that all information will be kept confidential and can only be released with my written
permission.
Yo autorizo y acepto los siguientes procedimientos de proyección para mi hijo mientras él o ella este matriculado en Options Full-day Preschool.
Entiendo que todos los exámenes y observaciones son llevados al cabo por personal de Options y consultores contractados. Padre o tutor será
informado si hay preocupaciones o se sospecha. Entiendo que toda la información será confidencial y sólo se puede liberar con mi permiso por
escrito.
Initial response / Ponga su inicial
Purpose – Each Screening assesses the child’s:
Screening/Prueba
Yes/Si
No
Propósito - cada investigación determina a niño:
a. Developmental Screening
cognitive, language and motor skills
Evaluación del desarrollo
habilidades cognitivas, de lenguaje y motrices
b. Ages and Stages Questionnaire: Social Emotional
social interactions, behavior and emotional health
Cuestionario de Edades y Etapas: Social Emocional
interacciones sociales, comportamiento y salud emocional
c. Dental Visual Exam
dental health
Examen Dental Visual
salud dental
d. Growth Assessment
body mass index / weight and height
Acesoramiento de crecimient
índice/peso y altura totales del cuerpo
e. Vision Screening
vision
Examen de la Vista
visión
f. Auditory Screening
hearing
Detección auditiva
audición
g. Mental Health Screening and Class Observation
mental health and well being
Observación de salud mental en la clase
salud y bienestar mentales
RELEASE OF MEDICAL INFORMATION / Autorización para dar información Medica
I, ______________________________________________________ authorize the release of medical information regarding
Yo
(Parent/ guardian name / Nombre del padre/ tutor)
autorizo que se de información medica tocante a
_____________________________________________________________ . Further, I consent to the above-noted screenings.
(Child’s Name/Nombre del Niño/a)
Además, yo consiento a los exámenes anotados arriba.
Signature of Parent/Guardian:Firma del Padre y/o guardián:_____________________________________________Date/Fecha:____________________
Signature of staff reviewing record: ___________________________________________________________________ Date: __________________________
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Dental Exam Permission Slip
I give permission for my child to have a DENTAL EXAM conducted by a licensed dentist at Options Full-day
Preschool. I authorize the dentist conducting the exam to release information to the Options Full-day
Preschool staff regarding my child’s dental exam. Upon the recommendation of the dentist, I agree to get
dental treatment for my child.
Child’s Name _____________________________________________ Birth Date _______________________
Parent’s Name _____________________________________ Telephone # ___________________________
Address _________________________________________________________________________________
Name of dental insurance: __________________________________________________________________
 Check here if no dental insurance
*Note to parents: This is not a definitive dental examination*
A dental office visit with the benefit of X-rays and dental instrument exploration is required for the dentist to
give you a complete evaluation of your child’s oral health.
This permission slip is valid while your child is enrolled with Options Full-day Preschool.
Parent’s Signature _________________________________________________ Date ___________________
------------------------------------------------------------------------------------------------------------------------------------------------------------------
Autorización de Examen Dental
Yo autorizo que mi hijo/a reciba un examen dental hecho por un dentista en el Options Full-day Preschool. Yo
autorizo que el dentista conduciendo el examen comparta información con representates del Options Full-day
Preschool tocante el examen dental de mi niño/a. Sobre la recomendación del dentista, yo estoy de acuerdo
en cumplir con el tratamiento de me hijo.
Nombre de Niño/a: _________________________________ Fecha de Nacimiento: ________________
Nombre de Padre: __________________________________ # de Teléfono: _____________________
Direccíon: __________________________________________________________________________
Nombre de aseguranza: _______________________________________________________________
 Marque aquí si no tiene aseguranza.
*Nota para padres: Esté examen no es definitive.*
Una visita a la oficina dental con el beneficio de rayos X y los instrumentos de exploracíon es necesario para
que el dentista le de una completa evaluacíon de la salud bucal de su hijo/a.
Esta hoja de permiso es valida mientras que su hijo/a este inscrito en Options Full-day Preschool.
Firma de Padre _____________________________________________
White – Site
Yellow – Office
Fecha___________________
Rev 5/14
Date
Nutrition Screening
Name of Child (Last, First)
Site
Birth date
Then  the best answer:
First Circle all the foods this child eats or drinks
1. Your child eats some of these foods
 4 or more servings a day
 Less than 4 servings a day
cheese
yogurt
milk
cottage cheese
soy milk
meat
fish
chicken
peanut butter
egg
beans
tofu
tortilla
cereal
potato
bread
lettuce
rice
corn
noodles
broccoli
crackers
tomato
green beans
 Less than 6 servings
spinach
apple
cucumber
pear
carrots
asparagus
cherry
pepper
banana
squash
grape
mango
kiwi
melon
citrus
peach
papaya
100% juice
 Less than 1 serving a day
fried food
chips
cake/pie
candy
energy drink
Answer these Questions: please circle yes or no
7. Does your child drink cola, tea, or coffee?
Yes
8. Does your child drink from a baby bottle or sippy cup?
Yes
9. Does your child eat dirt, clay, paint chips, ice, glue, or pencils? Yes
10. Does your child take iron supplements?
Yes
11. Does your child take fluoride supplements?
Yes
12. Does your child take vitamins?
Yes
13. Does your child have a diarrhea problem?
Yes
14. Does your child have a constipation problem?
Yes
15. Does your child skip breakfast often?
Yes
16. Does your child watch TV more than 1 hour/day?
Yes
17. Does your child play computer/video games more that 1hr/day? Yes
18. Does your child have physical activity less than 1 hour/day?
Yes
(walk, run, bike, swim, play outside, sports, etc.)
19. Are there any food or beverages your child cannot have
due to a food allergy?_____________________________
Yes
20. Are there any food or beverages your child cannot have
due to religious reasons?__________________________
Yes
No
No
No
No
No
No
No
No
No
No
No
No
soda
juice drink
21. Are you concerned about your child’s weight?
Yes
22. Are you concerned with your child’s eating habits?
Yes
23. My home needs running water, a stove, or a refrigerator?
Yes
24. Do you ever run out of food for your child or family?
Yes
25. Does your child have the WIC program?
Yes
26. Do you/your child have the CalFresh(food stamps) program? Yes
No
No
No
No
No
No
9,10 - Lead,
19,20 - Meal
21,22 - Nutrition 23-26 House, Food Bank,
Anemia Info Substitution Request
Referral
Food Stamp, WIC info
No
No
Parent Name: ____________________________ Parent Signature: _________________________ FSS initials: _____
Rev 11-11
Dental Exam
Site _____________________________
Child’s Name ____________________________________________________________ Birth Date__________________
Last
First
Parent’s Name ________________________________________________ Phone (_______) _________-____________
Address ________________________________________ City __________________________________ Zip __________
Type of Dental Insurance:
□ None □ Medi-Cal □ Healthy Family □ Private Insurance □ Other
Instructions for Dentist
Please fill out sections A, B, and C. Check all that apply, affix stamp, sign and date.
Have the parent return the completed form to the school. Thank you.
A. EXAM – Date completed: ______________________
_____ Visual Exam Only, without dental X-ray
_____ Dental Exam with X-ray
_____ Cleaning (prophylaxis)
_____ Fluoride
_____ Sealant
B. RESULT
_____ No further dental treatment required at this time.
Maintain child’s dental health with daily brushing and flossing.
Regular follow-up in _________ months
_____ Treatment required. Complete section C and indicate in diagram.
C. TREATMENT
_____ Needs the following treatment:
(circle)
Restoration
Pulpotomy
Crown
Extraction
Other: __________________________________________________________________
_____ Child has begun receiving treatment. Estimated number of follow up visits required: _____
Follow up appointments set for: ______________________________________________
_____ Child completed treatment on ___________________. Regular follow-up in __________ months
Dentist _______________________________________________________________
Phone ______________________________
Address ________________________________________ City __________________________________ Zip __________
Dentist Signature _________________________________________________________________ Date ______________________
White – Office
Yellow – Parent
(626) 858-0527

Fax (626) 859-0120
Rev 5-14
Family Strengths Assessment
Child’s Name:_________________________________________________
Date:________________________
In
Progress
Interested
Currently
Receiving
This Family Strength Assessment is to be completed with you to ensure that we work together in helping you develop goals to strengthen your family unit. This is the
beginning of the Family Partnership Agreement as we become more familiar with you and your family. Part two will consist of completing the Family Partnership Agreement.
Part three will be your Family Service Specialist following up with you during the school year to assist and provide support while accomplishing your goals.
Family Member
What can you identify as your family’s greatest strengths?
Health Services
Special Needs
Child Behavior Management (m)
Medical Services
Dental Services
Nutrition Services
Insurance
Prenatal Services
Education / Literacy
Health (k)
Adult Education (e)
GED (e)
Parenting Classes (m)
College / University (e)
ESL (d)
Legal Assistance
Child Support / Divorce (j)
Domestic Violence (i)
Citizenship / Immigration
Renters Rights
What can you identify as your most important
family or individual need at this time?
Vocational
Job Training (f)
Unemployment / EDD
Full Time Employment (f)
Part Time Employment (f)
Social Services
W.I.C. (a)
Food Assistance (a)
Housing Needs (a/b)
Clothing (a)
Holiday Donations (a)
Transportation Assistance
Veteran Support
Counseling
Individual (c )
Marriage (n )
Family
Financial
Drug/Alcohol Abuse (g)
Child Abuse /Neglect (h)
Incarcerated Family Member (l)
Education Status(circle):
A. Less than HS Graduate
B. HS Diploma or GED
C. Some Vocational/College or Associate Degree
D. Bachelor’s or Advance Degree
Parent’s Name: _____________________________________________Parent’s Signature: _______________________________________________
FSS Initial:
Original- Office
Yellow- Site
Rev 5-14

PTIONS Full-day Preschool

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