Physical Form

Name of child (last, first)(Required)

First Last

Date of birth (month, day, year)(Required)

Date of admission (month, day, year)

Address(Required)

Street Address City State ZIP Code

Child lives with (relationship)(Required)

Name(Required)

Telephone number(Required)

MEDICAL HISTORY

Communicable Disease

Month / Year

Screenings

TB Risk / Symptom

Result / Date (month, day, year)

Developmental Screen

Result / Date (month, day, year)

Lead

Result / Date (month, day, year)

Condition

Allergies:

Explain if present

Handicapping conditions:

Explain if present

Other:

Explain if present

PHYSICAL EXAMINATION

Date of exam (month, day, year)

Age of child

Skin

Lymphnodes

Eyes

Ears

Nasopharynx

Teeth and Mouth

Heart

Lungs

Abdomen

Genitalia

Skeleton

Other:

Note any unusual findings:

Does this child have any health condition that would be hazardou: as a result of participation in normal activities (including sports)?

Yes

If Yes, what modification of normal activities would be necessary to protect the child and the child's classmates:

Have you prescribed any medications or special routines which should be included in the center's plans for this child's activities? Explain:

Yes

If Yes, Please Explain:

HISTORY OF IMMUNIZATIONS AND TEST (indicate month / day / year)

DTAP | DT

Hib

IPV (Polio)

Influenza (Flu)

Measles Mumps Rubella (MMR)

Rotavirus (RGE)

Varicella (Varivax)

or Chicken Pox Disease

Month/year

Pneumococcal (PCV) (Prevnar)

HEP A

HBV (HEP B)

Recommended yearly.

Name of physician / nurse practitioner / physician assistant completing form (please print)

Telephone number

Signature of physician / nurse practitioner / physician assistant

ADDITIONAL NOTES AND INSTRUCTIONS

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Our hours have been adjusted based on valuable feedback and community needs to better serve our families.

Physical Form

MEDICAL HISTORY

Screenings

Condition

PHYSICAL EXAMINATION

HISTORY OF IMMUNIZATIONS AND TEST (indicate month / day / year)

ADDITIONAL NOTES AND INSTRUCTIONS

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