PHYSICIAN'S REPORT-CHILD CARE CENTERSPART A - PARENT'S CONSENT (To BE CoMPLETED BY PARENT)Name of Child*Birth Date* Date Format: MM slash DD slash YYYY is being studied for readiness to enterName of Child Care Center/School*This Child Care Center/School provides a program which extends from : HH MM AMPM to : HH MM AMPM days a week.Please provide a report on above-named child using the form below .I here by authorize release of medical information contained in this report to the above named Child Care Center.SIGNATURE OF PARENT,GUARDIAN,OR CHILD'S AUTHORIZED REPRESENTATIVETODAY'S DATE Date Format: MM slash DD slash YYYY PART B - PHYSICIAN'S REPORT (TO BE COMPLETED BY PHYSICIAN)Problems of which you should be aware:HearingAllergiesMedicineVisionInsect StingsDevelopmental:Food:Language/Speech:Asthma:Dental:Other(include behavioral concerns):MEDICATION PRESCRIBED/SPECIAL ROUTINES/RESTRICTIONS FOR THIS CHILD:IMMUNIXATION HISTORY:(Fill out or enclose california immunization Record,PM-298)VACCINEDATE EACH DOSE WAS GIVENPOLIO (OPV or IPV)Date (1ST) Date Format: MM slash DD slash YYYY Date (2ND) Date Format: MM slash DD slash YYYY Date (3RD) Date Format: MM slash DD slash YYYY Date (4TH) Date Format: MM slash DD slash YYYY Date (5TH) Date Format: MM slash DD slash YYYY DTP/DTaP/DT/Td (DIPHTHERIA.TETANUS AND [ACELLULAR] PERTUSSIS OE TETANUS AND DIPHTHERIA ONLY)Date (1ST) Date Format: MM slash DD slash YYYY Date (2ND) Date Format: MM slash DD slash YYYY Date (3RD) Date Format: MM slash DD slash YYYY Date (4TH) Date Format: MM slash DD slash YYYY Date (5TH) Date Format: MM slash DD slash YYYY MMR(MEASLES,MUMPS,AND RUBELLA)Date (1ST) Date Format: MM slash DD slash YYYY Date (2ND) Date Format: MM slash DD slash YYYY (Required For Child Care Only.) HIB MENINGITIS(HAEMOPHILUS 8)Date (1ST) Date Format: MM slash DD slash YYYY Date (2ND) Date Format: MM slash DD slash YYYY Date (3RD) Date Format: MM slash DD slash YYYY Date (4TH) Date Format: MM slash DD slash YYYY HEPATITIS BDate (1ST) Date Format: MM slash DD slash YYYY Date (2ND) Date Format: MM slash DD slash YYYY Date (3RD) Date Format: MM slash DD slash YYYY VARICELLA(CHICKEN POX)Date (1ST) Date Format: MM slash DD slash YYYY Date (2ND) Date Format: MM slash DD slash YYYY SCREENING OF TB RISK FACTORS(listing on reverse side)Risk factors not present;TB skin test not required. Risk factors present;Mantuox TB skin test performed(unless previous positive skin test documented).). Communicable TB disease not present.I have have not reviewed the above information with the parent/guardian.PhysicianDate of phsical Exam: Date Format: MM slash DD slash YYYY Address:Date This Form Completed : Date Format: MM slash DD slash YYYY Telephone:Signature: Physician Physician's Assistant Nurse Practitioner
