State Form 49969 - Child Care Center Health Record

ADVERTISEMENT

HEALTH CARE PROGRAM FOR CHILD CARE CENTERS
BUREAU OF CHILD CARE
CHILD CARE CENTER HEALTH RECORD
DIVISION OF FAMILY RESOURCES
State Form 49969 (R3 / 11-11)
Name of child (last, first)
Date of birth (month, day, year)
Date of admission (month, day, year)
Address (number and street, city, state, and ZIP code)
Child lives with (relationship)
Name
Telephone number
(
)
MEDICAL HISTORY
Communicable Disease
Month / Year
Condition
Explain if present
Allergies:
Measles
Rubella (German Measles)
Handicapping conditions:
Chickenpox
Mumps
Other:
Scarlet Fever
Whooping Cough
Other: _______________
PHYSICAL EXAMINATION
Age of child
Date of exam (month, day, year)
Skin
Heart
Lymphnodes
Lungs
Eyes
Abdomen
Ears
Genitalia
Nasopharynx
Skeleton
Teeth and Mouth
Other:
Note any unusual findings:
Does this child have any health condition that would be hazardous either to the child or to other children in a group setting as a result of participation in normal activities (including
sports)?
If Yes, what modification of normal activities would be necessary to protect the child and the child's classmates:
Yes
No
Have you prescribed any medications or special routines which should be included in the center's plans for this child's activities? Explain:
Yes
No
(Over)

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Medical
Go
Page of 2