PUMC Preschool - Medical Health Form
PUMC Preschool - Medical Health Form
Child’s Name: Date of Birth:
Physician’s Name:
Physician’s Address:
Physician’s Phone:
Parents please answer the questions listed below and have your child’s
****PHYSICIAN COMPLETE THE BACK SIDE OF THIS FORM ****
Does your child have:
Measles (rubeola) Yes / No Measles (rubella) Yes / No
Mumps Yes / No Whooping Cough Yes / No
Chicken Pox Yes / No Scarlet Fever Yes / No
Frequent sore throats Yes / No Frequent colds Yes / No
Fainting spells Yes / No Wears glasses Yes / No
Diabetic Yes / No Wears hearing aids Yes / No
Allergies Yes / No Has seizures Yes / No
If yes to allergies, please explain in detail exactly what the allergies are:
Date of last dental exam:
****************************************************************************************************
PUMC Preschool does NOT carry medical insurance. In case of an accident or serious illness, I understand that PUMC Preschool will make every reasonable effort to contact a parent, the child’s physician and the emergency contact. In the event the preschool is unable to make contact or immediate medical treatment is necessary, I authorize PUMC Preschool staff to authorize the necessary treatment for my child.
(Parent / Guardian Signature) (Date)
(Parent / Guardian Signature) (Date)
PHYSICIAN’S EXAM
History of Immunizations: Please indicate month/day/year
|DTap / DT / Td / TD |1 |2 |3 |4 |5 |
|OPV, IPV |1 |2 |3 |4 | |
|PVC |1 |2 |3 |4 | |
|Measles |1 |2 | | | |
|Mumps / MMR |1 |2 | | | |
|Rubella |1 |2 | | | |
|Hepatitis B |1 |2 |3 | | |
|Hib |1 |2 |3 |4 | |
|Prevnar (optional) | | | | | |
|Varicella | | | | | |
|(required for Kindergarten) | | | | | |
Height:
Weight:
Eyes/Vision:
Hearing:
Heart:
Lungs:
Date of last health exam:
Was this child, carried to full-term: Yes / No
If no, how many week premature was this child?
Were there any complications at this child’s birth: Yes / No
If yes, please explain:
Is there any medical history or health situation that may impact this child’s development
and ability to learn? Yes / No If yes, please explain in detail:
Physician’s Signature: ___________________________ Date:__________
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