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:

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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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