______ CHILD HEALTH & MEDICAL

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CHILD HEALTH FORMS & IMMUNIZATION RECORD TO BE COMPLETED BY PARENT OR GUARDIAN **NOTE: This form may be substituted with your pediatrician’s standard form, provided they are signed by the physician. CHILD INFORMATION/RELEASE:

_________________________________ ______ CHILD'S NAME (LAST, FIRST)

M.I

_____/ _____ / ______ DOB: MO

DAY

YEAR

___________________________________ ______________________ ___________

__________

CHILD’S ADDRESS

ZIP

CITY

STATE

WE/I GIVE PERMISSION TO OBTAIN/RELEASE MEDICAL HISTORY INFORMATION ON THE ABOVE CHILD. PARENT/GUARDIAN SIGNATURE:__________________________________________________ DATE: __________________________________________________ PLEASE RETURN TO: Casa dei Bambini Montessori Children’s Center * 507A South Street * Bow, NH 03304

HISTORY - TO BE COMPLETED BY PHYSICIAN (This information will be held confidential and will be used only for the benefit of this child)

CHILD HEALTH & MEDICAL HISTORY/INFORMATION: A. Prenatal, Perinatal and Postnatal Development: Any significant findings that could influence this child’s adaptations to a child care setting (i.e., physical handicap, sensory loss, developmental irregularities)? B. Any chronic illness that may require medication, particularly observations or precautions in a child care setting (i.e., recurrent ear infections, seizure disorder, allergies)? C. Any hospitalizations, operations, or special tests of which a child provider should be aware of? D. Pertinent family, social or health characteristics? Immunizations for Child Care Agency Attendance Parent may substitute a copy of child’s immunization record. Vaccine

Date

Date

Date

Date

Date

Date

DTP/DTAP HIB DTP-HIB TD OPV OR IPV MMR HEP-B VARICELLA OTHER Communicable Disease History Disease

CHICKENPOX OTHER

Date of Diagnosis

Recommended Screening/Testing Laboratory Confirmation N/A

Physician

Date

Method

TB ( HIGH RISK ONLY) VISION HEARING SPEECH HIB/HCT

N/A

URINE

N/A

LEAD

N/A

Result:

HEALTH ASSESSMENT: TO BE COMPLETED BY LICENSED HEALTH PRACTITIONER PHYSICAL EXAM: LENGTH/HEIGHT ______IN/CM %ILE______

CHECK ( ) EACH LINE

NORMAL

WEIGHT ______LB/KG %ILE_____

ABNORMAL

NEEDS FOLLOW-UP

NOT EXAMINED

SKIN /SCALP

HEAD CIRCUMFERENCE ______IN/CM %ILE______

CHECK ( ) EACH LINE

NORMAL

BLOOD PRESSURE ________/________

ABNORMAL

NEEDS FOLLOWUP

NOSE,THROAT, MOUTH TEETH & GUMS GLANDS, INC. THYROID

NUTRITION NEUROLOGY &MUSCULAR ORTHOPEDIC & SPINE EYES

CHEST, BREASTS

EARS

ABDOMEN

SPEECH

GENITALIA

HEART, LUNGS

TEMPERAMENT: EASY-GOING ___ COMMENTS:

AVERAGE ___

DIFFICULT ___

ALLERGIES: INCLUDE ALLERGIES TO FOOD, MEDICATION, OR OTHER SUBSTANCES:

ASSESSMENT OF PHYSICAL DEVELOPMENT: ESTIMATE OF LEVEL OF MATURATION: A. INFANCY (0-2 YEARS) EARLY: ____ MID: ____ LATE: ____ B. MID-PRESCHOOL (2-4 YEARS) EARLY: ____ MID: ____ LATE: ____ C. PRESCHOOL (4 YEARS) EARLY: ____ MID: ____ LATE: ____ D. SCHOOL-AGE (6-10 YEARS) EARLY: ____ MID: ____ LATE: ____ E. ADOLESCENT (11-18 YEARS) EARLY: ____ MID: ____ LATE: ____ COMMENTS:

ESTIMATE OF FUNCTIONAL CAPACITY: DELAYED FOR DEVELOPMENT PHASE

CONSISTENT WITH DEVELOPMENT PHASE

ADVANCED FOR DEVELOPMENT PHASE

GROSS MOTOR FINE MOTOR LANGUAGE SKILLS

SOCIAL SKILLS EMOTIONAL

_________________________________________ PHYSICIAN’S SIGNATURE

_______________ DATE OF EXAM

_________________________________________ PHYSICIAN'S NAME - TYPED OR PRINTED

_________________ TELEPHONE NUMBER

__________________________________ DATE OF NEXT SCHEDULED EXAM

COMMENTS

NOT EXAMINED

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______ CHILD HEALTH & MEDICAL

CHILD HEALTH FORMS & IMMUNIZATION RECORD TO BE COMPLETED BY PARENT OR GUARDIAN **NOTE: This form may be substituted with your pediatrician’s standard ...

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