Medical/Dental Checklist

How to access the information on this page:

  1. Directly on this page

2. Print it out as a hard copy

3. Download it and fill it out on your device, making updates anytime

Date: ___________________                           CASA Volunteer: please give copy of court entry/appointment to provider

Child’s name: _______________________________________________ Date of birth: __________________

Provider’s name: ____________________________________________ Phone: _______________________

Address: _________________________________________________________________

Collect Information, Monitor & Report

Review past records or contact previous providers

Obtain appointment history

Regular, routine services?

Obtain mental health assessments, such as DAF

A comprehensive health assessment has been performed since placement in foster care

Immunizations are complete & up-to-date

Medical concerns:

For healthy development, has the child received: 

A hearing screening?

A vision screening?

A lead exposure screening?

A communicable disease screening?

A developmental screening?

A mental health screening?

If pre-kindergarten, ennrollment in an Early Childhood Program?

If an adolescent, received healthy development information?

Collect Dental Information, Monitor & Report

Review past records or contact previous providers

Obtain appointment history

Regular, routine dental services?

Dental concerns: