Form LIC702 "Child's Preadmission Health History - Parent/Authorized Representative Report" - California

What Is Form LIC702?

This is a legal form that was released by the California Department of Social Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2019;
  • The latest edition provided by the California Department of Social Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form LIC702 by clicking the link below or browse more documents and templates provided by the California Department of Social Services.

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Download Form LIC702 "Child's Preadmission Health History - Parent/Authorized Representative Report" - California

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State of California – Health and Human Services Agency
California Department of Social Services
CHILD’S PREADMISSION HEALTH HISTORY - PARENT/AUTHORIZED
REPRESENTATIVE REPORT
CHILD’S NAME
SEX
BIRTHDATE
PARENT / AUTHORIZED REPRESENTATIVE NAME
DOES PARENT / AUTHORIZED
REPRESENTATIVE LIVE IN
HOME WITH CHILD?
PARENT / AUTHORIZED REPRESENTATIVE NAME
DOES PARENT / AUTHORIZED
REPRESENTATIVE LIVE IN
HOME WITH CHILD?
IS / HAS CHILD BEEN UNDER REGULAR SUPERVISION OF
DATE OF LAST PHYSICAL/
PHYSICIAN?
MEDICAL EXAMINATION
DEVELOPMENTAL HISTORY (*For infants and preschool-age children only)
WALKED AT*
BEGAN TALKING AT*
TOILET TRAINING STARTED AT*
________________ MONTHS
________________ MONTHS
________________ MONTHS
PAST ILLNESSES — Check illnesses that child has had and specify approximate dates of
illnesses:
DATES
DATES
DATES
… Diabetes
… Poliomyelitis
… Chicken Pox
… Epilepsy
… Ten-Day
… Asthma
Measles
… Whooping
… Rheumatic
(Rubeola)
Cough
Fever
… Three-Day
… Mumps
… Hay Fever
Measles
(Rubella)
SPECIFY ANY OTHER SERIOUS OR SEVERE ILLNESSES OR ACCIDENTS
DOES CHILD HAVE FREQUENT
HOW MANY IN LAST YEAR? LIST ANY ALLERGIES STAFF
COLDS?
YES
NO
SHOULD BE AWARE OF
LIC 702 (10/19) (CONFIDENTIAL)
Page 1 of 3
State of California – Health and Human Services Agency
California Department of Social Services
CHILD’S PREADMISSION HEALTH HISTORY - PARENT/AUTHORIZED
REPRESENTATIVE REPORT
CHILD’S NAME
SEX
BIRTHDATE
PARENT / AUTHORIZED REPRESENTATIVE NAME
DOES PARENT / AUTHORIZED
REPRESENTATIVE LIVE IN
HOME WITH CHILD?
PARENT / AUTHORIZED REPRESENTATIVE NAME
DOES PARENT / AUTHORIZED
REPRESENTATIVE LIVE IN
HOME WITH CHILD?
IS / HAS CHILD BEEN UNDER REGULAR SUPERVISION OF
DATE OF LAST PHYSICAL/
PHYSICIAN?
MEDICAL EXAMINATION
DEVELOPMENTAL HISTORY (*For infants and preschool-age children only)
WALKED AT*
BEGAN TALKING AT*
TOILET TRAINING STARTED AT*
________________ MONTHS
________________ MONTHS
________________ MONTHS
PAST ILLNESSES — Check illnesses that child has had and specify approximate dates of
illnesses:
DATES
DATES
DATES
… Diabetes
… Poliomyelitis
… Chicken Pox
… Epilepsy
… Ten-Day
… Asthma
Measles
… Whooping
… Rheumatic
(Rubeola)
Cough
Fever
… Three-Day
… Mumps
… Hay Fever
Measles
(Rubella)
SPECIFY ANY OTHER SERIOUS OR SEVERE ILLNESSES OR ACCIDENTS
DOES CHILD HAVE FREQUENT
HOW MANY IN LAST YEAR? LIST ANY ALLERGIES STAFF
COLDS?
YES
NO
SHOULD BE AWARE OF
LIC 702 (10/19) (CONFIDENTIAL)
Page 1 of 3
State of California – Health and Human Services Agency
California Department of Social Services
DAILY ROUTINES (*For infants and preschool-age children only)
WHAT TIME DOES CHILD GET
WHAT TIME DOES CHILD GO
DOES CHILD SLEEP WELL?*
UP?*
TO BED?*
DOES CHILD SLEEP DURING
WHEN?*
HOW LONG?*
THE DAY?*
DIET PATTERN:
BREAKFAST
(What does child usually eat for
these meals?)
LUNCH
DINNER
WHAT ARE USUAL EATING
BREAKFAST
HOURS?
LUNCH
DINNER
ANY FOOD DISLIKES?
ANY EATING PROBLEMS?
IS CHILD TOILET TRAINED?*
IF YES, AT WHAT
ARE BOWEL MOVEMENTS
WHAT IS USUAL
YES
NO
STAGE:*
REGULAR?*
TIME?*
YES
NO
WORD USED FOR “BOWEL MOVEMENT”*
WORD USED FOR URINATION*
PARENT / AUTHORIZED REPRESENTATIVE EVALUATION OF CHILD’S HEALTH
IS CHILD PRESENTLY
IF YES, NAME OF
DOES CHILD TAKE
IF YES, WHAT KIND
UNDER A DOCTOR’S CARE?
DOCTOR:
PRESCRIBED
AND ANY SIDE
YES
NO
MEDICATION(S)?
EFFECTS:
YES
NO
DOES CHILD USE ANY
IF YES, WHAT KIND: DOES CHILD USE ANY
IF YES, WHAT KIND:
SPECIAL DEVICE(S):
SPECIAL DEVICE(S) AT
YES
NO
HOME?
YES
NO
PARENT/ AUTHORIZED REPRESENTATIVE EVALUATION OF CHILD’S PERSONALITY
LIC 702 (10/19) (CONFIDENTIAL)
Page 2 of 3
State of California – Health and Human Services Agency
California Department of Social Services
HOW DOES CHILD GET ALONG WITH PARENT / AUTHORIZED REPRESENTATIVE, BROTHERS,
SISTERS AND OTHER CHILDREN?
HAS THE CHILD HAD GROUP PLAY EXPERIENCES?
DOES THE CHILD HAVE ANY SPECIAL PROBLEMS/FEARS/NEEDS? (EXPLAIN.)
WHAT IS THE PLAN FOR CARE WHEN THE CHILD IS ILL?
REASON FOR REQUESTING DAY CARE PLACEMENT
PARENT/AUTHORIZED REPRESENTATIVE SIGNATURE
DATE
LIC 702 (10/19) (CONFIDENTIAL)
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