Health Consultation Log
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1HEALTH CONSULTATION LOG
(Sample Form)
Group or Center’s Name ____________________________________ Date _____/_____/_____ Time in: _____Time out: _____
License #__________
Activities Conducted During The Visit:
Adequate
Inadequate
Follow-up
Not-
Needed
applicable
Review of health records and immunization records of staff
Review of health and immunization records of children
Review of contents, storage and plan for maintenance of the first aid
kits
Observation of the indoor and outdoor environments for health and
safety
Observation of children’s general health and development
Observation of diaper changing and toileting areas
Observation of diaper changing, toileting and hand washing
procedures
Review of policies and procedures and required documentation for
the administration of medications, including petitions for special
medication authorization
Assist in the review of individual care plans for children with
special health care needs/disabilities
Individual child(ren)/classrooms observed: (LIST)
__________________________________________________
___________________________________________________
__________________________________________________
___________________________________________________
__________________________________________________
___________________________________________________
__________________________________________________
Supplementary/Reference materials shared: (LIST)
__________________________________________________
___________________________________________________
__________________________________________________
___________________________________________________
__________________________________________________
___________________________________________________
__________________________________________________
Communication with staff about specific problems (LIST)
__________________________________________________
___________________________________________________
__________________________________________________
___________________________________________________
__________________________________________________
___________________________________________________
__________________________________________________
Other consultation provided or recommended: (LIST)
__________________________________________________
___________________________________________________
__________________________________________________
___________________________________________________
__________________________________________________
___________________________________________________
__________________________________________________
______________________________________
____________________________ _____/_____/_____
Signature of Health Consultant
Title
Date
G_C_HealthConsultationLog
Feb 2014
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Parent category: Medical