HEALTH RECORD

To be completed by a parent. Please SIGN and DATE below. This information will be held confidential and will be used only to benefit the child. Please Print Clearly

1.     Any significant findings that could influence the child's adaptations to program setting, any special considerations or adaptations  needed? (physical handicaps, developmental irregularities)

2.    Any Chronic illness that may require regular medication, and other observations or precautions in program setting? (seizure disorder, chronic ear infections, allergies to drugs, food or environment, other allergies) Please list diet modifications or special medications.

3.    Any Potential exposure to any contagious diseases during the last 3 weeks?  Any other medical conditions that the staff should  be aware of? Any special considerations or needs.

4.    Pertinent family, social, health or emotional issues or characteristics?

IMMUNIZATION & INFECTIOUS DISEASE HISTORY:

                                                        Date of immunization                                  Date of illness

POLIO, Oral                                                                                                                                
POLIO, Salk                                                                                                                                
DIPHTHERIA                                                                                                                              
TETANUS                                                                                                                                   
WHOOPING COUGH                                                                                                                
MEASLES                                                                                                                                   
MUMPS                                                                                                                                      
RUBELLA                                                                                                                                   
CHICKEN POX                                                                                                                          
SCARLET FEVER                                                                                                                       
OTHER                                                                                                                                        

TESTS:
TB                                                                                                                                                
VISION                                                                                                                                       
HEARING                                                                                                                                   
SPEECH                                                                                                                                      

Physician Name                                                                                   Phone                                
Medical Insurance Coverage: YES/NO Company                                                     ID#               

In case of emergency, I hereby give permission to the medical personnel selected by the program, in my absence, to act as agent, to secure proper treatment for, hospitalize, to order routine tests, X-rays and other medical treatment for my child as named above. Every effort will be made possible to contact the parents in the event of an emergency.

Parent Signature                                                                                                Date