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MONTHLY HEALTH ACTIVITY SHEET Case Number ____________
Please Submit With Your Monthly Notes If Any
Health Related Activities Occurred During The Month
Child’s Name: _____________________________________________________ Case Worker: _____________________________
Foster Parent/ Provider Name:____________________________________________________________
Treatment Type: Dental Medical Mental Specialist Vision
Name, Address & Phone of Physician/ Hospital/ Provider: Date of Appointment/s:
(Use as many lines as needed)
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Type of Service:
30 day Healthchek 60 day Healthchek Annual Healthchek Illness
Injury Follow-up Non- Annual Physical Lab/ Testing
Cleaning/ Exam Orthodontist Mental Assessment Diagnostic
Eye Glasses/contacts Procedure/ Surgery Immunization Pre- Natal
Other: Please specify ________________________________________________________________________________
Further Description if needed: _____________________________________________________________________________
List Why child went to Doctor –( Illness, injury, immunization- list each immunization separately) &
Results of Appointment (Diagnosis, Medications, what doctor did)
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Does the child have to go back for a follow-up visit? Yes No
If yes, Date of follow-up appointment/s:__________________________Will transportation be needed? Yes No
Foster Parent/ Providers’ Name: ________________________________________________ Date: ____________
Social Workers’ Name: __________________________________________________ Date: ____________
Columbiana County Department of Job & Family Services
Children Services
7989 Dickey Dr. Suite 2
Lisbon, OH 44432
(330) 420-6600 FAX (330) 424-0931