FAMILY AND SOCIAL SERVICES
HEALTH CARE PROGRAM FOR CHILD CARE
ADMINISTRATION - MS02
HEALTH RECORD - CHILD
402 W. Washington St., Room W362
State Form 49969 (R5 / 7-19)
Indianapolis, IN 46204
Name of child (last, first)
Date of birth (month, day, year)
Date of admission (month, day, year)
Address (number and street, city, state, and ZIP code)
Child lives with (relationship)
Name
Telephone number
(
)
MEDICAL HISTORY
Communicable Disease
Month / Year
Condition
Explain if present
Allergies:
Handicapping conditions:
Screenings
Result / Date (month, day, year)
TB Risk / Symptom
Other:
Developmental Screen
Lead
PHYSICAL EXAMINATION
Date of exam (month, day, year)
Age of child
Skin
Heart
Lymphnodes
Lungs
Eyes
Abdomen
Ears
Genitalia
Nasopharynx
Skeleton
Teeth and Mouth
Other:
Note any unusual findings:
Does this child have any health condition that would be hazardous either to the child or to other children in a group setting as a result of participation in normal activities (including sports)?
If Yes, what modification of normal activities would be necessary to protect the child and the child's classmates:
Yes
No
Have you prescribed any medications or special routines which should be included in the center's plans for this child's activities? Explain:
Yes
No
(Over)
