PHYSICIAN'S REPORT-CHILD CARE CENTERS

  • PART A - PARENT'S CONSENT (To BE CoMPLETED BY PARENT)

  • Date Format: MM slash DD slash YYYY
  • is being studied for readiness to enter

  • This Child Care Center/School provides a program which extends from

  • :
  • to

  • :
  • 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.
  • Date Format: MM slash DD slash YYYY
  • PART B - PHYSICIAN'S REPORT (TO BE COMPLETED BY PHYSICIAN)


  • IMMUNIXATION HISTORY:

    (Fill out or enclose california immunization Record,PM-298)
  • VACCINE
  • DATE EACH DOSE WAS GIVEN
  • POLIO (OPV or IPV)
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • DTP/DTaP/DT/Td (DIPHTHERIA.TETANUS AND [ACELLULAR] PERTUSSIS OE TETANUS AND DIPHTHERIA ONLY)
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • MMR(MEASLES,MUMPS,AND RUBELLA)
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • (Required For Child Care Only.) HIB MENINGITIS(HAEMOPHILUS 8)
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • HEPATITIS B
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • VARICELLA(CHICKEN POX)
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY

  • SCREENING OF TB RISK FACTORS(listing on reverse side)
  • Communicable TB disease not present.

  • reviewed the above information with the parent/guardian.

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY

Ready to join the family?