Health and Education Questionnaire - California 2026

1. Click ‘Get Form’ to open the Health and Education Questionnaire in the editor.
2. Begin by entering your name, address, and relationship to the child in the designated fields. This information is crucial for identifying who is providing the details.
3. Fill in the child's date of birth and place of birth, including city, state, country, and hospital. This section helps establish essential background information.
4. Detail any medical problems the child may have by checking 'Yes' or 'No' and providing descriptions for allergies, injuries, diseases, disabilities, or other conditions as applicable.
5. Indicate if the child is taking any prescribed medications. If so, list them along with their purposes.
6. Provide information about healthcare providers who have seen the child. Include names and addresses along with dates of last visits.
7. Complete sections regarding dental evaluations and insurance coverage by answering questions about recent visits and types of insurance held.
8. Finally, provide details about the child's educational background including school attendance, grade level, learning disabilities, special needs, and primary language spoken at home.

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