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(801) 224-4449
orem@mykidsconnection.org
Orem, UT
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Child Health Assessment
There must be a separate health assessment form for each sibling.
Name of Child
(Required)
First
Last
Birth Date
MM slash DD slash YYYY
Email
(Required)
Does your child have any known allergies or sensitivities to:
Check All That Apply:
Medications
Yes
No
Please list:
(Required)
Foods
Yes
No
Please list:
(Required)
Other
Yes
No
Please list:
(Required)
Illnesses or Medical Conditions:
Does your child have any of the following conditions?
Asthma
(Required)
Yes
No
Visual Impairment
(Required)
Yes
No
Diabetes
(Required)
Yes
No
Developmental Delays
(Required)
Yes
No
Seizures
(Required)
Yes
No
Physical Impairment
(Required)
Yes
No
Heart Problems
(Required)
Yes
No
Behavioral or Emotional Problems
(Required)
Yes
No
Hearing Impairment
(Required)
Yes
No
Other:
List any additional health information or special instructions you feel we need to be aware of:
List any regular medications your child takes:
Name of Child's Medical Provider:
(Required)
Phone Number For Medical Provider
(Required)
Parent/Guardian Name
(Required)
Date
(Required)
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CAPTCHA
Home
Programs
Infants
Toddlers
Preschool
Before and After School Program
Summer Camp
About
About Us
Tuition Support
Careers
Parent Reviews
Why Choose Us
Our Rate Information
Virtual Tour
Location
Parent Corner
Contact Us
