Health Inventory - Enrollment Bright Horizons Page 3
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4PART II - CHILD HEALTH ASSESSMENT
To be completed ONLY by Physician/Nurse Practitioner
Child’s Name:
Birth Date:
Sex
Last
First
Middle
Month / Day / Year
M
F
1. Does the child named above have a diagnosed medical condition?
No
Yes, describe:
2. Does the child have a health condition which may require EMERGENCY ACTION while he/she is in child care? (e.g., seizure, allergy, asthma,
bleeding problem, diabetes, heart problem, or other problem) If yes, please DESCRIBE and describe emergency action(s) on the emergency card.
No
Yes, describe:
3. PE Findings
Not
Not
Health Area
WNL
ABNL
Health Area
WNL
ABNL
Evaluated
Evaluated
Attention Deficit/Hyperactivity
Lead Exposure/Elevated Lead
Behavior/Adjustment
Mobility
Bowel/Bladder
Musculoskeletal/orthopedic
Cardiac/murmur
Neurological
Dental
Nutrition
Development
Physical Illness/Impairment
Endocrine
Psychosocial
ENT
Respiratory
GI
Skin
GU
Speech/Language
Hearing
Vision
Immunodeficiency
Other:
REMARKS: (Please explain any abnormal findings.)
4. RECORD OF IMMUNIZATIONS – DHMH 896/or other official immunization document (e.g. military immunization record of immunizations) is
required to be completed by a health care provider or a computer generated immunization record must be provided. (This form may be obtained
from:
Select DHMH 896.
RELIGIOUS OBJECTION:
I am the parent/guardian of the child identified above. Because of my bona fide religious beliefs and practices, I object to any immunizations being
given to my child. This exemption does not apply during an emergency or epidemic of disease.
: ____________________________________________________
: _____________________
Parent/Guardian Signature
Date
5. Is the child on medication?
No
Yes, indicate medication and diagnosis:
(OCC 1216 Medication Authorization Form must be completed to administer medication in child care).
6. Should there be any restriction of physical activity in child care?
No
Yes, specify nature and duration of restriction:
7. Test/Measurement
Results
Date Taken
Tuberculin Test
Blood Pressure
Height
Weight
BMI %tile
Lead Test Indicated:
Yes
No
has had a complete physical examination and any concerns have been noted above.
_______________________________
(Child’s Name)
Additional Comments:
_____________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Physician/Nurse Practitioner (Type or Print):
Phone Number:
Physician/Nurse Practitioner Signature:
Date:
OCC 1215 - Revised August 2015 - All previous editions are obsolete.
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