Maryland Online IFSP

General Health

What was your child’s gestational age at birth?

Child’s gestational age

What was your child’s birth weight? Enter weight in pounds & ounces OR in grams.

pounds

ounces

Calculate Grams

grams

Calculate Pounds / Ounces

Who is your primary care physician or other health care professional?

Physician Name

Physician Phone Enter numbers only

Immunizations

** Are your child’s immunizations up to date?

Yes

No

Not Sure

N/A

* If No or Not Sure, Please indicate the strategies to be used to ensure up-to-date immunizations by the time your child may be ready to transition to community / school early childhood program.

Lead Screening / Testing

** Has your child’s lead level been tested?

Yes

No

* What was the level?

** Are there any concerns about your child's lead level?

Yes

No

* Please explain

Nutrition

** Are there any concerns about your child's eating, general nutrition, or growth?

Yes

No

* Please explain

General Health Concerns

Consider your child’s current health status. Is there anything about your child’s health (special equipment, allergies, other mental or physical information) that the team should know to better plan and provide services to your child and family, including specific diagnoses?

Upload Medical Report / Info

Comment

Add comments to edits made in this session for Version History tracking (optional) Add comments to edits Briefly describe edits made within this session Add comments to edits made in this session for Version History tracking (optional)

Jasfer May at risk eligible new child

I. Information about my Child's Development:
Health Information

General Health

Immunizations

Lead Screening / Testing

Nutrition

General Health Concerns

Comment

Jasfer May at risk eligible new child

I. Information about my Child's Development: Health Information

view_day General Health

view_day Immunizations

view_day Lead Screening / Testing

view_day Nutrition

view_day General Health Concerns

view_day Comment

I. Information about my Child's Development:
Health Information

General Health

Immunizations

Lead Screening / Testing

Nutrition

General Health Concerns

Comment