2020 Health Screening Form

Fill OUT ONCE A YEAR PER FAMILY

Family Name:

Date:

Please list all children living in the home:

Add another child

Who do the children live with? Lives with:

Parents Foster Family Joint Custody Single Custody Other:

If you selected Single Custody, who do they live with:

If you selected Other, please specify:

Does your child belong to any of the following ethnic groups?

American Indian

African American

Hispanic American

Asian/South Pacific Islands

Caucasian

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

Is there a family history of tuberculosis or suspicion of tuberculosis in any family member?

Yes No

Was this child or his/her parents born in South America, Africa, Central America, Southeast Asia or any other foreign country?

Yes No

Have any members of the family in close contact been in jail or prison?

Yes No

Do you live in the city of Chicago or in a neighborhood that is known to have high prevalence of tuberculosis?

Yes No

Have you or your child traveled out of the country in the last year or have you had visitors from out of the country?

Yes No

If Yes, where?

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

1. Is any child in your family eligible for or enrolled in Medicaid, Head Start, All Kids, or WIC?

Yes No

2. Does any child in your family have siblings with a blood level of 6 mcg/dl or higher?

Yes No

3. Does any child in your family live in or regularly visit a home built before 1978?

Yes No

4. In the past year, has this child been exposed to repairs, repainting or renovations of a home built before 1978?

Yes No

5. Are any of your children a refugee or an adoptee from any foreign country?

Yes No

6. Has any child in your family been to Mexico, Central or South American, or any Asian country?

Yes No

7. Does any child in your family live with someone who has a job or hobby that may involve lead (for example: jewelry making, construction, plumbing, automobiles, lead solders, leaded glass, lead shots, lead finishing sinkers?)

Yes No

8. At any time, has your family lived near a factory where lead is used?

Yes No

9. Does your family reside in a high-risk ZIP code area? (Such as, Chicago, Winnetka, River Forest, Evanston, Brookfield, Riverside, Highland Park, Oak Park)

Yes No

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)

Food Allergies:

Y N DK

If yes, who and describe: (Which family member and also Maternal or Paternal side of the family)

Nasal Allergies:

Y N DK

If yes, who and describe: (Which family member and also Maternal or Paternal side of the family)

Asthma:

Y N DK

If yes, who and describe: (Which family member and also Maternal or Paternal side of the family)

Bedwetting (after 6 years old)

Y N DK

If yes, who and describe: (Which family member and also Maternal or Paternal side of the family)

Childhood hearing loss:

Y N DK

If yes, who and describe: (Which family member and also Maternal or Paternal side of the family)

Eye Disorders/ Congenital Abnormalities/ Retinoblastoma:

Y N DK

If yes, who and describe: (Which family member and also Maternal or Paternal side of the family)

Epilepsy/ Seizures:

Y N DK

If yes, who and describe: (Which family member and also Maternal or Paternal side of the family)

Migraines or other Neurological Disorder:

Y N DK

If yes, who and describe: (Which family member and also Maternal or Paternal side of the family)

Developmental Disabilities:

Y N DK

If yes, who and describe: (Which family member and also Maternal or Paternal side of the family)

Autism/ Cognitive Delay:

Y N DK

If yes, who and describe: (Which family member and also Maternal or Paternal side of the family)

ADHD:

Y N DK

If yes, who and describe: (Which family member and also Maternal or Paternal side of the family)

Immune Problems, HIV, Tuberculosis:

Y N Dk

If yes, who and describe: (Which family member and also Maternal or Paternal side of the family)

Thyroid Problems or other Endocrine Disease:

Y N DK

If yes, who and describe: (Which family member and also Maternal or Paternal side of the family)

Autoimmune Disease:

Y N DK

If yes, who and describe: (Which family member and also Maternal or Paternal side of the family)

Anemia:

Y N DK

If yes, who and describe: (Which family member and also Maternal or Paternal side of the family)

Genetic or Heritable Disease:

Y N DK

If yes, who and describe: (Which family member and also Maternal or Paternal side of the family)

Orthopedic Disorders: (example: Hip Dysplasia, Scoliosis, Osteoporosis)

Y N DK

If yes, who and describe: (Which family member and also Maternal or Paternal side of the family)

Bleeding, or Blood Disorder:

Y N DK

If yes, who and describe: (Which family member and also Maternal or Paternal side of the family)

Stomach/ Intestinal Problems:

Y N DK

If yes, who and describe: (Which family member and also Maternal or Paternal side of the family)

Liver Disease:

Y N DK

If yes, who and describe: (Which family member and also Maternal or Paternal side of the family)

Kidney Disease/ Urologic Malformations:

Y N DK

If yes, who and describe: (Which family member and also Maternal or Paternal side of the family)

Heart Abnormalities: (congenital heart disease, valve abnormalities, arrhythmias, hypertrophic cardiomyopathy, etc.)

Y N DK

Please Specify which abnormality/disease:

Hypertension/ High Blood Pressure:

Y N DK

If yes, who and describe: (Which family member and also Maternal or Paternal side of the family)

High Cholesterol or takes cholesterol medication:

Y N DK

If yes, who and describe: (Which family member and also Maternal or Paternal side of the family)

Heart Attack: (before age 60)

Y N DK

If yes, who and describe: (Which family member and also Maternal or Paternal side of the family)

Stroke:

Y N DK

If yes, who and describe: (Which family member and also Maternal or Paternal side of the family)

Diabetes:

Y N DK

If yes, who and describe: (Which family member and also Maternal or Paternal side of the family)

Obesity:

Y N DK

If yes, who and describe: (Which family member and also Maternal or Paternal side of the family)

Cancer: (before age 55)

Y N DK

If yes, who and describe: (Which family member and also Maternal or Paternal side of the family)

Depression:

Y N DK

If yes, who and describe: (Which family member and also Maternal or Paternal side of the family)

Anxiety:

Y N DK

If yes, who and describe: (Which family member and also Maternal or Paternal side of the family)

Eating Disorder:

Y N DK

If yes, who and describe: (Which family member and also Maternal or Paternal side of the family)

Other mental Illness:

Y N DK

If yes, who and describe: (Which family member and also Maternal or Paternal side of the family)

Any other significant family history?

Y N DK

Please Specify:

Does either parent smoke cigarettes, vape or use any tobacco product?

Y N DK

If yes, who and describe: (Which family member and also Maternal or Paternal side of the family)

Is your child exposed to smoke from any tobacco product at home or on a regular basis?

Y N DK

If yes, who and describe: (Which family member and also Maternal or Paternal side of the family)

Substance/ Drug Abuse:

Y N DK

If yes, who and describe: (Which family member and also Maternal or Paternal side of the family)

Are there guns in the house?

Y N DK

If yes, who and describe: (Which family member and also Maternal or Paternal side of the family)

Do your children visit any house where guns are kept?

Y N DK

If yes, who and describe: (Which family member and also Maternal or Paternal side of the family)

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