Form Lic 701 - Physician'S Report - Child Care Centers printable pdf download

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

STATE OF CALIFORNIA

COMMUNITY CARE LICENSING

HEALTH AND HUMAN SERVICES AGENCY

PHYSICIAN’S REPORT—CHILD CARE CENTERS

(CHILD’S PRE-ADMISSION HEALTH EVALUATION)

PART A – PARENT’S CONSENT

(TO BE COMPLETED BY PARENT)

__________________________________________, born ________________________________ is being studied for readiness to enter

(NAME OF CHILD)

(BIRTH DATE)

_________________________________________ . This Child Care Center/School provides a program which extends from _____ : ____

(NAME OF CHILD CARE CENTER/SCHOOL)

a.m./p.m. to ______ a.m./p.m. , __________ days a week.

Please provide a report on above-named child using the form below. I hereby authorize release of medical information contained in this

report to the above-named Child Care Center.

__________________________________________________________

_________________

(SIGNATURE OF PARENT, GUARDIAN, OR CHILD’S AUTHORIZED REPRESENTATIVE)

(TODAY’S DATE)

PART B – PHYSICIAN’S REPORT

(TO BE COMPLETED BY PHYSICIAN)

Problems of which you should be aware:

Hearing:

Allergies: medicine:

Vision:

Insect stings:

Developmental:

Food:

Language/Speech:

Asthma:

Dental:

Other (Include behavioral concerns):

Comments/Explanations:

MEDICATION PRESCRIBED/SPECIAL ROUTINES/RESTRICTIONS FOR THIS CHILD:

IMMUNIZATION HISTORY: (Fill out or enclose California Immunization Record, PM-298.)

DATE EACH DOSE WAS GIVEN

VACCINE

1st

2nd

3rd

4th

5th

POLIO (OPV OR IPV)

(DIPHTHERIA, TETANUS AND

DTP/DTaP/

[ACELLULAR] PERTUSSIS OR TETANUS

DT/Td

AND DIPHTHERIA ONLY)

(MEASLES, MUMPS, AND RUBELLA)

MMR

(REQUIRED FOR CHILD CARE ONLY)

(HAEMOPHILUS B)

HIB MENINGITIS

HEPATITIS B

VARICELLA

(CHICKENPOX)

SCREENING OF TB RISK FACTORS (listing on reverse side)

■ ■

Risk factors not present; TB skin test not required.

■ ■

Risk factors present; Mantoux TB skin test performed (unless

previous positive skin test documented).

___ Communicable TB disease not present.

■ ■

I have

have not

reviewed the above information with the parent/guardian.

Physician:_______________________________________________

Date of Physical Exam: ___________________________________

Address:________________________________________________

Date This Form Completed: _______________________________

Telephone: ______________________________________________

Signature ______________________________________________

■ ■

Physician

Physician’s Assistant

Nurse Practitioner

LIC 701 (8/08) (Confidential)

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Form Lic 701 - Physician'S Report - Child Care Centers

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