Fill and Sign the Health and Education Questionnaire California Form

JV-225 CHILD'S NAME: CASE NUMBER: ––––– ––––– HEALTH AND EDUCATION QUESTIONNAIRE TO THE PARENT OR GUARDIAN OF THE CHILD: The law requires that the social worker or probation officer learn your child's medical, dental, mental health, and educational background. Please answer as many questions as you can so the necessary help may be provided to you and your child. 1. Your name: ––––– a. Address: ––––– ––––– b. Relationship to child: ––––– 2. What is the child's date of birth? ––––– 3. Where was the child born? a. City, state, and country: ––––– ––––– b. Hospital: ––––– c. Child's birth weight: ––––– 4. Does the child have any medical problems? Yes No (If yes, please describe): a. Allergies: ––––– b. Injuries: ––––– c. Diseases: ––––– d. Disabilities: ––––– e. Other: ––––– f. Other: ––––– Continued in Attachment 4. 5. Is the child taking any prescribed medicines? Yes No (If yes, please list them and indicate what they are treating): ––––– ––––– ––––– Continued in Attachment 5. 6. What doctor, clinic, or hospital has the child's medical and mental health records, if any? (List names and addresses of all who have seen the child, and the date of the last visit): a. ––––– b. ––––– c. ––––– Continued in Attachment 6. 7. When was the child last seen by a dentist? Date: ––––– (Name and address of dentist): ––––– ––––– Check here if child has not been seen by a dentist. Page 1 of 2 Form Adopted tor Mandatory Use HEALTH AND EDUCATION QUESTIONNAIRE Welfare and Institutions Code, § 16010 Judicial Council of California JV-225 [Rev. January 1, 2006] electronic form ã 2005 WWW.LawCA.co m Law Publishers JV-225 CHILD'S NAME: CASE NUMBER: ––––– ––––– 8. When was the child's sight last evaluated? Date: ––––– (Name and address of doctor): ––––– ––––– Check here if child's sight has never been evaluated. 9. Does the child wear glasses? Yes No 10. Is the child covered by an insurance policy? a. Medical No Yes (specify): ––––– b. Dental No Yes (specify): ––––– c. Vision No Yes (specify): ––––– 11. Has the child been attending day care? school? a. What grade is he or she in? ––––– b. Does he or she have any learning disabilities? Yes No (If yes, please describe): ––––– ––––– c. Does he or she have any special needs? Yes No (If yes, please describe): ––––– ––––– d. What is his or her primary language? ––––– e. (List names and addresses of schools and dates last attended): ––––– ––––– ––––– ––––– ––––– ––––– Date: ––––– ––––– (TYPE OR PRINT NAME) (SIGNATURE OF SOCIAL WORKER OR PROBATION OFFICER) JV-225 [Rev. January 1, 2006] HEALTH AND EDUCATION QUESTIONNAIRE Page 2 of 2