Get Health Demographics Form

The Health Demographics Form is a crucial document used to collect essential information regarding a child's health and demographics. This guide will provide you with a comprehensive, step-by-step approach to completing the form online, ensuring that you provide all necessary details effectively.

Follow the steps to complete the Health Demographics Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In the Personal Information section, enter the child's name, date of birth, suffix, social security number, Title XIX number, gender, and agency home.
3. Provide the Referral Source by circling the appropriate option such as care coordinator, family planning, or school.
4. In Discharge Information, indicate the discharge reason by selecting from options like moved, new, or requested transfer.
5. In the Other Programs section, circle all relevant programs such as before/after school care or early Head Start.
6. Fill out the Ethnicity & Language Information section, specifying ethnicity, country of origin, primary race, and indicate if a translator is needed.
7. Complete the Family & Household Information by entering the address, family size, primary and secondary phone numbers, and monthly income.
8. Provide information under the Parent & Guardian Information section, circling marital status and recording the education level achieved for each parent or guardian.
9. In the Medical Home Information section, answer questions about the usual source of medical care and insurance status.
10. Complete the Dental Home Information, answering questions regarding dental care, insurance, and recent visits.
11. Indicate if the client has any developmental delays or disabilities under Early ACCESS and list any delay types if applicable.
12. Review all the information provided for accuracy, then save your changes, download, print, or share the form as required.

Start filling out the Health Demographics Form online today to ensure your child's health information is up-to-date.