Child'S Health Resume Page 2
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1
2Are your child’s immunizations up to date? Yes
No
Allergies
Does your child have any known drug allergies? Yes
No
If Yes, what are they and what are your child’s reactions?
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Does your child have any known food allergies? Yes
No
If Yes, what are they and what are your child’s reactions?
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Does your child have any other allergies? Yes
No
If Yes, what are they and what are your child’s reactions?
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Other Medical Information
Does your child take any medication on a regular basis? Yes
No
If Yes, please give the name of the medication and the
medical condition for which it is taken. ____________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Was your child born prematurely?
Yes
No
If Yes, how many weeks? ________________________________________
Do you have any concerns about your child’s development?
Yes
No
If Yes, please comment. ____________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Are there any restrictions on the kind and/or amount of physical activity in which your child may participate?
Yes
No
If Yes, please identify. __________________________________________________________________________________________
_____________________________________________________________________________________________________________
Has your child ever undergone surgery?
Yes
No
If Yes, please list. __________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Are there any special diets necessary for your child’s health?
Yes
No
If Yes, please describe.
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Please comment on any other medical information the child care service should be aware of. ________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Date: _______/_______/_______
___________________________________________________
Year
Month
Day
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