Medical History And Physical Examination Form printable pdf download

Medical History And Physical Examination Form

Huguenot Street Cooperative Nursery School

Medical History and Physical Examination Form

To be completed by parent/guardian:

Child _________________________________________________ Birth Date ____________________

Address ______________________________________________ Phone ________________________

Mother’s Name ____________________________ Father’s Name ______________________________

Doctor to be called in an emergency ________________________ Phone ________________________

Illnesses of note (chronic, allergies, sensitivities, etc.): ________________________________________

To be completed by a Physician:

Required Immunizations:

Dates:

DTaP or DT

_____

MMR

_____

IPV

_____

HIB

_____

Hepatitis B

_____

Varicella

_____

Physical Examination:

Date of exam: ________________

Weight _____

Height_____

Teeth_____

Tonsils_____

Eyes_____

Ears_____

Glands_____

Skin_____

Abdomen_____

Hernia_____

Heart_____

Lungs_____

Orthopedic_________________________

Audio Test__________________________

Are there any physical defects to be corrected? _____________________________________________

Are there any medical conditions to note in the event of an emergency?__________________________

____________________________________________________________________________________

In my opinion, is the applicant physically able to participate in any nursery school activity?

Yes ___ No ___ Explain: ______________________________________________________________

Doctor’s Signature ______________________________________________ Date _________________

Medical History And Physical Examination Form

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