Fillable Family Screening Profile

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Family Screening Profile

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  • 60 other fields

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File type: PDF

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Family Screening Profile
Regional Office of Education #08
27 S. State Ave., Suite 101, Freeport, IL 61032
Phone: 815.599.1408 Fax: 815.297.9032
www.roe8.com
Child’s Name:
_______
____________________ ____________ ________________________
First Middle Last
Date of Birth:
_____/
_____/ ____
Month Day Year
Birth Place:
City
State
County Other:
Home Address:
_______
_______________________________ ______________________ ________
Street Address City Zip Code
Residing School District:
_______
_____________
Medical Information
Notes:
1. Has your child or anyone in your household been
tested for COVID-19 within the last 14 days?
Additional Information:
2. Does your child have any allergies to food?
Additional information:
3. Does your child have any allergies to medications?
Additional information:
4. Does your child have any other types of allergies?
Additional information:
5. Is your child currently under a physician’s care for
anything other than general wellness physicals?
Additional information:
6. Does your child have any other conditions that we
should know about?
Description:
7. Has your child taken medicine in the last 24 hours?
8. Do you have concerns about your child’s health?
9. Has your child ever been hospitalized?
10. Has your child ever had a serious injury?
11. Has your child had seizures or fainting spells?
12. Has your child experienced lead poisoning?
Level:
13. Has your child had a chronic illness?
14. Has your child ever been evaluated for ADD
/ADHD?
15. Was your child full term?
Birth weight:
Birth length:
Please describe any complications during pregnancy or the birth of your child:
Female
No
No
No
No
No
No
No
No
Family Screening Profile
Regional Office of Education #08
27 S. State Ave., Suite 101, Freeport, IL 61032
Phone: 815.599.1408 Fax: 815.297.9032
www.roe8.com
General Information
Did an agency refer you to screening or our program?
Examples:
CFC (Child & Family Connections)
FHN Parent Enrichment Program
FHN Pediatric Rehab
DCFS (Department of Children & Family Services)
WIC Program
Local Health Department
Child’s Physician
If so please list agency and date
of services if applicable:
Does your child currently attend a preschool program (public or
private)?
Does anyone in your family have a history of drug or alcohol
abuse?
Does your family have a history of physical violence?
Has your child ever lived outside the home for an extended time?
Does any household member have any serious illness or handicap?
Have any of your child’s siblings had difficulty in school?
Did either of your child’s parents have difficulty in school?
Does your child currently have a chance to play with others his/her
own age?
Other:
Has your family recently experienced
Other/ Additional Information:
Are you currently receiving:
Other Assistance or Support?
Daycare
Relatives
Playgroups
Church
Moving
Adoption
Unemployment
Restraining Order
Medicaid/ ALL Kids
Childcare Subsidy Payments
LINK/SNAP
WIC
TANF
No
No
No
No
No
No
No
No
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Family Screening Profile

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Completed 10 March 2021

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