Form Dcd-0108 - Children'S Medical Report printable pdf download

Children’s Medical Report

Name of Child_______________________________________________Birthdate ______________________

Name of Parent or Guardian__________________________________________________________________

Address of Parent of Guardian________________________________________________________________

A. Medical History (May be completed by parent)

1. Is child allergic to anything? No___ Yes___ If yes, what?

2. Is child currently under a doctor's care? No___ Yes___ If yes, for what reason?

3. Is the child on any continuous medication? No___ Yes___ If yes, what?

4. Any previous hospitalizations or operations? No___ Yes___ If yes, when and for what?

5. Any history of significant previous diseases or recurrent illness? No___ Yes___ ; diabetes No___Yes___;

convulsions No___ Yes___; heart trouble No___ Yes___; asthma No___ Yes___.

If others, what/when?

6. Does the child have any physical disabilities: No___ Yes___ If yes, please describe:

Any mental disabilities? No___ Yes___ If yes, please describe:

Signature of Parent or Guardian_____________________________________________Date____________

B. Physical Examination: This examination must be completed and signed by a licensed physician, his authorized

agent currently approved by the N. C. Board of Medical Examiners (or a comparable board from bordering

states), a certified nurse practitioner, or a public health nurse meeting DHHS standards for EPSDT program.

Height _________%

Weight __________%

Head____________ Eyes_____________ Ears_____________ Nose___________ Teeth__________Throat___________

Neck_________ Heart_________Chest_________Abd/GU_______________Ext__________

Neurological System___________________________Skin__________________Vision____________Hearing_________

Results of Tuberculin Test, if given: Type__________date__________ Normal___Abnormal_________followup________

Developmental Evaluation: delayed________age appropriate___________

If delay, note significance and special care needed;__________________________________________________

__________________________________________________________________________________________

Should activities be limited? No___ Yes___ If yes, explain: ______________________

Any other recommendations:____________________________________________________________________________

___________________________________________________________________________________________________

__________________________________________________________________________________________________

Date of Examination__________

Signature of authorized examiner/title___________________________________Phone #_______________

DCD-0108

12/99

Form Dcd-0108 - Children'S Medical Report