Mo 580-1878 - Child Medical Examination Report (Infant/toddler/pre-School) printable pdf download

Mo 580-1878 - Child Medical Examination Report (Infant/toddler/pre-School)

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MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES

SECTION FOR CHILD CARE REGULATION

CHILD MEDICAL EXAMINATION REPORT (INFANT/TODDLER/PRE-SCHOOL)

RESET

IDENTIFYING INFORMATION

CHILD’S NAME

BIRTHDATE

CURRENT STATE OF HEALTH

Based on my assessment of this child’s medical history, current state of health and my physical examination of the child on ____ / ____ / ____,

this child can participate in a child care program. This child has no special care needs unless specified below.

(Date of medical examination must be within the last 12 months.)

PHYSICIAN’S INSTRUCTIONS FOR SPECIALIZED CARE

Complete this section only if child requires special care at a child care facility, e.g. special diets, allergies, ear infections, convulsions,

diabetes, asthma, behavior problems, hearing or visual impairment, etc. (Attach additional pages as needed.)

SIGNATURE OF PHYSICIAN OR REGISTERED NURSE UNDER THE SUPERVISION OF A PHYSICIAN

DATE

PHYSICIAN’S OR NURSE’S NAME (PLEASE PRINT)

NAME AND ADDRESS OF CLINIC, GROUP, PRACTICE OR OTHER

IF NURSE IS SUPERVISED BY A PHYSICIAN, INDICATE PHYSICIAN’S NAME

(MAY USE STAMP.)

(PLEASE PRINT.)

TELEPHONE NUMBER

MO 580-1878 (6-14)

BCC-6A

TO BE FILED IN CHILD’S RECORD AT CHILD CARE FACILITY

Mo 580-1878 - Child Medical Examination Report (Infant/toddler/pre-School)