Child & Adolescent Health Examination Form

The Department of Health makes it easier for parents and providers to record health examinations for children and adolescents. Every child attending a NYC school (public or private), day care service, early intervention program or day camp must have a yearly health examination. This new form takes the place of the 211S School Form and the 318KA Day Care Form.

If your child has not seen their primary care provider in over a year, please schedule an appointment by calling 1-718-606-FUND (3863). You may fill out the parent or guardian portion of the form below and send it to us via the HappyHealthyMe portal under ‘My Messages’ and you may attach the form so we have it in our possession prior to the visit.

Find the copy of the form here.

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