Anamnesebogen Schuleingangsuntersuchung

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Allgemeine Angaben Kind

Vorerkrankungen Kind

Sorgeberechtigte

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Date

Verstecktes Feld

komXflow Informationen

Vorgangsname

tfkomXSuchordner

Status

Did you receive the invitation letter for the school entry exam in the mail yet?*

yes

The Public Health Authority will send out letters of invitation to the pre-school medical examination by post, in stages according to the child’s age. Please do not complete the online medical history form until you have received the letter of invitation.

Personal Information of the child

last name*

first name*

date of birth*

number of siblings*

nationality*

country of birth*

Kindergarten

How many years did the child go to kindergarden?*

Does your child currently go to kindergarden?*

yes

Type of kindergarden*

regular kindergarden

pre-school facility

curative day care center

integrative place

other

Which other kindergarten does your child attend?*

Pregnancy and birth

birthweight (in gramm)*

completet weeks of pregnancy*

Is the child a twin/multiple?*

yes

Developement

Are there speech impairments?*

yes

If so, which ones?*

Is the child multilingual?*

yes

Since when does the child have contact with the german language?*

since birth

not since birth

From whiche age on does the child have contact with the german language?*

mothertounge first custodial party*

german

other

mothertounge*

mothertounge second custodial party*

german

other

mothertounge*

Which languages are spoken at home?*

german

other

other languages*

Is the child*

righthanded

lefthanded

still undecided

Would you say that, overall, your child has difficulties in one or more of the following areas: mood (gloomy, anxious, unstable, short-tempered), concentration (cannot sit still for long, does not listen persistently when reading), behavior, interaction with others ?*

yes

Here you can tell us in which area your child has difficulties:

Support measures or treatments

Participation in "Vorkurs Deutsch"*

yes

planned

Speech therapy*

completed

ongoing

planned

no need

Warteliste

Name of the practice or institution:

Speech therapy*

completed

ongoing

planned

no need

Warteliste

Occupational therapyOccupational therapy*

completed

ongoing

planned

no need

Warteliste

Special needs education*

completed

ongoing

planned

no need

Warteliste

Physiotherapy*

completed

ongoing

planned

no need

Warteliste

Pre-existing health conditions or health restrictions

Did the child already visit an eye docotor?*

yes

Findings*

unobtrusive

glasses

short sighted (myopia)

far sighted (hyperopia)

cross eyed

Did the child visit a dentist in the last 12 months?*

yes

Does the child have a congenital severe hearing impairment?*

yes

Congenital hearing impairment*

left side

right side

both sides

Acquired hearing impairment*

left side

right side

both sides

hearing aid*

left side

right side

both sides

none

cochlea-implant*

left side

right side

both sides

none

Does the child have a metabolism oder hormonal disorder? (only if diagnosed by a doctor)*

yes

Which hormonal disorder does the child have?*

MCAD deficiency

hypothyroidism

PKU

CAH

cystic fibrosis

diabetes typ 1

Sickle cell disease

Spinal muscular atrophy (SMA)

others

Which other hormonal disorder does the child have?*

age of diagnosis*

Does the child have other chronic illnesses?*

yes

Which other chronic illnesses does the child have?*

Does the child have a severe disability?*

yes

Which severe disablity does the child have?*

Does the child have to take medication regularly?*

yes

Which kind of medication has to be taken regularly?*

Does the child have any known illenesses for which a certain type of action is necessary? (e.g. epilepsie)*

yes

Which kind of illness illness is it?*

Preventive medical examinations

Has your child undergone the U8 preventive medical checkup?

yes

For children aged 5 and above: Has the U9 preventive medical checkup been carried out?

yes

Family

Does a reading and spelling weakness run in the family? (dyslexia)*

yes

Does a calculation weakness run in the family? (dyscalculia)*

yes

Legal guardians

Legal guardian 1

name*

first name*

Adress*

postcode*

city*

telefone*

e-mail

Sorgberechtigte Person 2

name

first name

Adress

postcode

city

telefone

e-mail

Legal guardian 2

Voluntary information

Providing the following information is voluntary. However, your information is important for the further development of preventive measures. Further information on data processing can be found in the data protection information that you received together with the invitation to the school entrance examination.

Your answers will be sent to the LGL anonymously. If you revoke your consent prior to transmission to the LGL by notifying the health authority responsible for you, this data will not be transmitted to the LGL. If you revoke your consent after it has been sent to the LGL, it is possible that your data has already been merged with other data and evaluated anonymously and a revocation can therefore no longer be implemented.

Do you want to give voluntary information about the legal guardians?*

yes

number of adults in the houshold

First legal guardian

country of birth

Germany

Other country

nationality

german

german + other

other

Degree

None

Lower secondary leaving certificate

High School diploma

A-Levels / baccalaureate

University degree

Employment

full-time employment (> 35 h)

part-time employment (15 - 34 h)

part-time employment (< 15 h)

on leave (e.g. maternity leave)

apprentice

unemployed, not looking for employment

unemployed, looking for employment

Second legal guardian

country of birth

Germany

Other country

nationality

german

german + other

other

Degree

None

Lower secondary leaving certificate

High School diploma

A-Levels / baccalaureate

University degree

Employment

full-time employment (> 35 h)

part-time employment (15 - 34 h)

part-time employment (< 15 h)

on leave (e.g. maternity leave)

apprentice

unemployed, not looking for employment

unemployed, looking for employment

Datenschutzrechtliche Hinweise nach Art.13 DSGVO: www.landratsamt-dachau.de/dsgvo/schuleingangsuntersuchung/

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