Preschool Health Card
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1Jewish Community Center of Dallas
Aaron Family JCC • 7900 Northaven Road • Dallas, Texas 75230-3392 • 214-739-2737 • Fax 214-368-4709
Camp health CarD: CHAI, SIMCHAH and TEEN TRAVEL
thiS SeCtion mUSt Be CompleteD By phySiCian (pleaSe print)
Child’s Name _________________________________________________________________ Date of Birth ______/______/______
Physician’s Name______________________________________________________________ Phone____________________________
Physician’s Address _________________________________________ ______________________________________ ____________
Street
City/State
Zip
Height ________________ Weight ___________________
1. allerGy / meDiCationS
List any special problems that your child may have, such as allergies, existing illness, injuries during the past 12 months or any medication
prescribed for long-term continuous use:
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
i haVe eXamineD thiS ChilD anD FoUnD him / her to Be in GooD health anD aBle to partiCipate in
normal aCtiVitieS.
2.
______________________________________________________________________________ _____/______/______
Signature of physician
Date of last exam
Varicella (chickenpox) is not required if your child has had chickenpox disease.
My child had varicella disease (chickenpox) on or about (date) _______________ and does not need varicella vaccine.
_____________________________________________________________________________ ________________________________
Parent Signature
Date
Date / Booster
immUniZationS
Date / Dose 1
Date / Dose 2
Date / Dose 3
Date / Booster
Dtp / Dtap / Dt
polio (ipV or opV)
mmr
hiB
hepatitis a
hepatitis B
( )
( )
Date:
T.B. test
Positive
Negative
(upon enrollment)
pneumococcal (pVC7)
Varicella
(see below)
3.
______________________________________________________________________________ _____/______/______
Signature of physician or health personnel
(immunization record Verification)
Date
Vision – Date ______/______/______ J Passed
J Failed
Hearing – Date ______/______/______ J Passed
J Failed
Child’s Dentist __________________________________________________________________________ _______________________
Dentist’s Name
Phone
note:
If medical diagnosis and treatment and / or immunization and TB testing conflict with your religious beliefs, you must sign an affidavit to that effect
and attach it to this form. If immunization and / or TB testing would be injurious to your child or family, you must obtain a certificate (signed by a physician)
to that effect and attach it to this form.
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