2020 Health Screening Form

Please correct the errors described below.

Fill OUT ONCE A YEAR PER FAMILY

Please list all children living in the home:

Add another child

Respond to the following questions by selecting the appropriate answer TB:

Lead Risk Assessment: (FILL THIS SECTION OUT ONLY FOR CHILDREN UNDER 6 YEARS OF AGE)

FIlL OUT THIS SIDE OF THE ANNUAL FORM IF INSTRUCTED BY TODAY'S NURSE OR IF THERE HAS BEEN ANY CHANGE TO YOUR FAMILY HISTORY IN THE LAST YEAR

( Y = YES, N = NO, DK = DON'T KNOW )

Does anyone in your family (1st and 2nd generation) has a history of: (Mother, Father, Grandparents, Aunts, Uncles and 1st cousins)

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