Fill and Sign the Jv 225 Your Childs Health and Education Form

JV-225CHILD'S NAME: CASE NUMBER: HEALTH AND EDUCATION QUESTIONNAIRETO 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? YesNo(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? YesNo(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 2Form Adopted tor Mandatory Use HEALTH AND EDUCATION QUESTIONNAIRE Welfare and Institutions Code, § 16010Judicial Council of CaliforniaJV-225 [Rev. January 1, 2006]electronic form  2005 WWW.LawCA.com Law Publishers JV-225CHILD'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? YesNo10. Is the child covered by an insurance policy?a. Medical NoYes (specify): b. Dental NoYes (specify): c. Vision NoYes (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? YesNo (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