COMO PARK LANGUAGE AND ARTS PRESCHOOL AND CHILDCARE CENTER
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Health form

HEALTH CARE SUMMARY

Date of Enrollment: _________________

NAME OF CHILD ___________________________________________ Birth Date ______________

ADDRESS __________________________________________________ Telephone _____________

PARENT(S) OR GUARDIAN ___________________________________________________________________

Date of last physical examination ____________ How long have you been seeing this child? ________________

How frequently do you see this child when he/she is not ill? _____________________________________________

Does this child have any allergies (including allergies to medications)? _____________________________________

Is a modified diet necessary? _____________________________________________________________________

Is any condition present that might result in an emergency? _____________________________________________

____________________________________________________________________________________________

What is the status of the child’s. . . Vision __________________________________________________

Hearing _________________________________________________

Speech __________________________________________________

Please list below the important health problems

Followed Followed By Other Requires Special

Important Health Problems _By You__ Med Source (Name) Attention at Center

____________________________________________________________________________________________

____________________________________________________________________________________________

Other information helpful to the child care program ______________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

Phone _______________________

Signature of Health Source _____________________________ Address ________________________________

Date ______________________________ ______________________________________

MS-2083

MUST BE COMPLETED BY HEALTH CARE SOURCE







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