Staying Healthy Assessment 3-4 years

State of California - Health and Human Services Agency

Department of Health Care Services
Staying Healthy
Child's Name (first & last)
Date of Birth

MonthDayYear
Date
Gender

FemaleMale
Today's Date

MonthDayYear
Date
In Child/Day care?

YesNo
Person Completing Form

ParentRelativeFriendGuardianOther
Need Help with Form?

YesNo
Need Interpreter?

YesNo
Please answer all the questions on this form as best you can. Mark "Skip" if you do not know an answer or do not wish to answer. Be sure to talk to the doctor if. you have questions about anything on this form. Your answers will be protected as part of. your medical record.
Does your child drink or eat 3 servings of calcium-rich foods daily, such as millk, cheese, yogurt, soy milk, or tofu?

YesNoSkip
Does your child eat fruits and vegetables at least two times per day?

YesNoSkip
Does your child eat high fat foods, such as fried foods, chips, ice cream, or pizza more than once per week?

NoYesSkip
Does your child drink more than one small cup (4-6 oz) of juice per day?

NoYesSkip
Does your child drink soda, juice drinks, sports drinks, energy drinks, or other sweetened drinks more than once per week?

NoYesSkip
Does your child play actively most days of the week?

YesNoSkip
Are you concerned about your child's weight?

NoYesSkip
Does your child watch TV or play video games less than 2 hours per day?

YesNoSkip
Does your home have a working smoke detector?

YesNoSkip
Have you turned your water temperature down to low-warm (less than 120 degrees)?

YesNoSkip
If your home has more than one floor, do you have safety guards on the windows and gates for the stairs?

YesNoSkip
Does your home have cleaning supplies, medicines, and matches locked away?

YesNoSkip
Does your home have the phone number of the Poison Control Center (800-222-1222) posted by your phone

YesNoSkip
Do you always stay with your child when she/he is in the bathtub?

YesNoSkip
Do you always place your child in a rear facing car seat in the back seat?

YesNoSkip
Is the car seat you use the right one for the age and size of your child?

YesNoSkip
Do you always check for children before backing your car out?

YesNoSkip
Does your child spend time near a swimming pool, river, or lake?

NoYesSkip
Does your child spend time in a home where a gun is kept?

NoYesSkip
Does your child always wear a helmet when riding a bike, skateboard, or scooter

YesNoSkip
Has your child ever witnessed or been a victim of abuse or violence?

NoYesSkip
Do you help your child brush and floss her/his teeth daily?

YesNoSkip
Does your child spend time with anyone who smokes?

NoYesSkip
Do you have any other questions or concerns about your child's health, development or behavior?

NoYesSkip
If yes, please describe
Should be Empty: