Health Inventory Form - Child'S Personal Record For Child Care Facilities - Maryland State Department Of Education Page 3
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4PART II: MEDICAL
INFORMATION
HEALTH PRACTITIONER
CHILD'S NAME: ___________________________________
To be completed by a
1. Date of this child's most
recent
tuberculin test:
___/ ___/___
Result:
____ Positive ____ Negative
Under Maryland law, a child under the age of six must have appropriate screening/testing for lead poisoning. See page 4.
2. Date of this child’s lead screening: ___/___/___
Blood lead test dates: Test 1: ___/___/___
Test 2: ___/___/___
3. This child has the following which may significantly affect his/her child care experience:
(COMMENTS)
a. Vision problem
YES
NO
b.
Hearing problem
YES
NO
c.
Speech or language problem
YES
NO
d.
Other physical illness or
impairment
YES
NO
e.
Mental, emotional or behavior problems
YES
NO
f.
Developmental delays
YES
NO
g.
Allergies
YES
NO
Significant physical findings, comments and recommendations:
4. This child has a health condition which may require care or emergency action while at child care.
YES
NO
If YES, please
specify
(e.g.,
seizures,
bee sting allergy, diabetes, etc.):
Recommendations:
5. This child has or is a known carrier of a communicable disease which should prevent his/her admission to a child care facility or school.
YES
NO If YES, please specify:
6. This child requires a modified diet and/or special feeding procedures.
YES
NO
If YES, please specify:
7.
If this
child cannot fully participate in all areas of the child care program, what areas should be limited or altered to suit his/her needs?
____________________________________________________________________________________________________________
8. Does this child's physical activity need to be restricted?
YES
NO
If YES, please specify:
9. Does this child require any specialized treatment?
YES
NO
If YES,
please
specify:
10. Does this child require any adaptive equipment
(braces,
crutches,
etc.)?
YES
NO
If YES, please specify type:
Special instructions for use:
RECORD OF IMMUNIZATIONS
Vaccine Types
Enter: Month/Day/Year for each immunization administered
Dose #
DTP-
Polio
HIB
Hep B
PCV7
MMR
Varicella
Rotavirus
MCV4
HPV
Hep A
Other
DTAP
1
2
3
4
5
OCC 1215 - Revised 6/08 - All previous editions are obsolete and replaces OCC 1215A, OCC 8506 and use of DHMH 896.
Page 3 of 4
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