Authorization For Emergency Medical Attention Page 2
ADVERTISEMENT
1
2MEDICAL HISTORY
Child’s Name ______________________________________________ Birthday _____________________________ Sex ________
Please circle if your child has had the following:
Mumps
No
Yes
Chicken Pox
No
Yes
Rubella
No
Yes
Whooping Cough
No
Yes
Polio
No
Yes
Meningitis
No
Yes
Flu
No
Yes
Convulsions
No
Yes
Blood Sugar Problems No
Yes
If so, what? _______________________________________________________
Any evidence of hearing loss or difficulties?
No
Yes
Any evidence of vision difficulties?
No
Yes
Hospitalization?
No
Yes
If yes, for what & when __________________________
__________________________________________________________________________________________________
Other Illnesses? ____________________________________________________________________________________
__________________________________________________________________________________________________
MEDICAL STATEMENT TO BE COMPLETED BY PHYSICIAN
State law requires that this medical statement MUST be on file in the school office on the FIRST day of
school and MUST be current within ONE YEAR.
I have examined ________________________________________________ and found him/her to be free of
communicable diseases and is physically and mentally able to participate in the Preschool/Mother’s Day Out program.
Furthermore I acknowledge that his/her inoculations are up to date and were given as follows:
Vaccines
Date
Date
Date
Date
Date
Hepatitis A
Hepatitis B
DTaP/DTP/DT/Td
Hib
Polio
Prevnar/PCV
MMR
Varicella
TB Test
Result
.
Any allergies or special recommendations? _______________________________________________________________
________________________________________________________________________
Physician’s Signature
Date
__________________________________________________________________________________________________
Physician’s Name (Type or Print)
Address
City
State
Zip
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form B - Authorization For Emergency Medical Care - Kansas Department Of Health And Environment
Legal
Medication Authorization For Cms Students Form/authorization For Self-medication By Cms Students Form - 2006
Medical
Authorization For Dispensing Medications To Children And Youth Long-term Medications (prescription And Non-prescription) - Kansas Department Of Health And Environment
Legal
Related Categories
Parent category: Business