Children Health Service Forms

Table of Content


CHS-1 Request for a Special Diet (English)

CHS-1 Request for a Special Diet (Spanish)


CHS-2 Intervention Packet

CHS-3 Authorization to Release ECI and ISD

Individual Teacher Response Form

Heath Record Booklet

Completed Health Record Booklet (All Forms)
Form 1 – General Information
Form 2A – Health History
Form 2B – Health History
Form 3 – Physical Examination Assessment
Form 5 – Dental Health
Form 6 – Nutrition
Form 9 – Psychological and Social Development
Form 10 – Staff Observation of Health and Behavior

Mental Health

Mental Health Referral Packet (For Referral Use Only)