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	85 Copley Avenue Teaneck, New Jersey 07666
	Phone: 201-801-0291
	ganyaldenu@gmail.com

Child health Record

Child Health Record

Section l - TO BE COMPLETED BY PARENT(S)
Child's Name(Last)*
Child's Name First*
Gender*
- Male
- Female
Date of Birth*
Does Child Have Health Insurance?*
- Yes
- No
If Yes, Name of Child's Health Insurance Carrier*
Parent/Guardian Name*
Home Telephone Number*
Work Telephone/Cell Phone Number*
Parent/Guardian Name*
Home Telephone Number*
Work Telephone/Cell Phone Number*
I give my consent for my child's Health Care Provide and Child Care Provider/School Nurse to discuss the information on this form.
Signature*
Date*
This form may be released to WIC*
- Yes
- No
Section II - TO BE COMPLETED BY HEALTH CARE PROVIDER
Date of Physical Examination*
Results of physical examination normal?*
- Yes
- No
Abnormalities Noted
Weight
(must be taken within 30 days for WIC)
Height
(must be taken within 30 days for WIC)
Head Circumference
(if < 2 Years)
Blood Pressure
(if >= 3 Years)
IMMUNIZATIONS*
- Immunization Record Attached
- Date Next Immunization Due
MEDICAL CONDITIONS
Chronic Medical Conditions Related Surgeries
List medical conditions ongoing surgical concerns
- None
- Special Care Plan Attached
Comments
Medications/Treatments
List medications/treatments
- None
- Special Care Plan Attached
Comments
Limitations to Physical Activity
List limitations/special considerations
- None
- Special Care Plan Attached
Comments
Special Equipment Needs
List items necessary for daily activities
- None
- Special Care Plan Attached
Comments
Allergies/Sensitivities
List allergies
- None
- Special Care Plan Attached
Comments
Special Diet/Vitamins & Mineral Suppliments
List dietary specifications
- None
- Special Care Plan Attached
Comments
Behavioral Issues/Mental Health Diagnosis
List behavioral/mental health issues/concerns
- None
- Special Care Plan Attached
Comments
Emergency Plans
List emergency plan that might be needed and the signs/symptoms to watch for.
- None
- Special Care Plan Attached
Comments
PREVENTIVE HEALTH SCREENINGS
Type Screening Date Performed Record Value
Hgb/Het
Lead
- Capiliary
- Vanous
TB (mm of Induction)
Other
Other
Type Screening Date Performed Note if Abnormal
Hearing
Vision
Dental
Developmental
Scollosis
*
- I have examined the above student and reviewed his/her health history. It is my opinion that he/she is medically cleared to participate fully in all child care/school activities , including physical education and competitive contact sports, unless noted above.
Name of Health Care Provider (print)
Signature
Date*
Health Care Provider Stamp

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