Child Medical Exam

IDENTIFYING INFORMATION

CHILD'S NAME(Required)

First Last

BIRTHDATE(Required)

PARENT/GUARDIAN'S EMAIL ADDRESS

CURRENT STATE OF HEALTH

Based on my assessment of this child's medical history, ourrent state of health and my physical examination of the child on(Required)

this child can participate in a child care program. This child has no special care needs unless specified below.

(Date of medical examination must be within the last 12 month.)

PRYSICIAN'S INSTRUCTIONS FOR SPECIALIZED CARE

Complete this section only if child requires special care at a child care facility, e.g. special diets, allergies, ear infections, convulsions, diabetes, asthma, behavior problems, hearing or visual impairment, etc. (Attach additional pages as needed.)

Attach additional pages as needed

Max. file size: 300 MB.

SIGNATURE OF PHYSICIAN OR REGISTERED NURSE UNDER THE SUPERVISION OF A PHYSICIAN(Required)

Date(Required)

PHYSICIAN'S OR NURSE'S NAME (PLEASE PRINT)

NAME AND ADDRESS OF CLINIC, GROUP, PRACTICE OR OTHER (MAY USE STAMP)

IF NURSE IS SUPERVISED BY A PHYSICIAN, INDICATE PHYSICIAN'S NAME (PLEASE PRINT)

TELEPHONE NUMBER

Child Medical Exam

IDENTIFYING INFORMATION

CURRENT STATE OF HEALTH

(Date of medical examination must be within the last 12 month.)

PRYSICIAN'S INSTRUCTIONS FOR SPECIALIZED CARE

TO BE FILED IN CHILD'S RECORD AT CHILD CARE FACILITY

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