CASAEARLYLEARNING.COM
HEALTH CARE SUMMARY
MUST BE COMPLETED BY HEALTH CARE SOURCE
Date of Enrollment:_____________________
Child’s name: _____________________________________________ Date of birth: ___________________
Address: __________________________________________________Telephone: _____________________
Parent(s) or Guardian: ______________________________________________________________________
Date of last physical examination __________ How long have you been seeing this child? ___________
How frequently do you see this child when he/she is not ill? _____________________________________
Does this child have any allergies (including allergies to medications)? __________________________
Is a modified diet necessary? ______________________________________________________________
Is any condition present that might result in an emergency? ____________________________________’
___________________________________________________________________________________________
What is the status of the child’s. . . Vision __________________________________________
Hearing __________________________________________
Speech __________________________________________
Followed Followed By Other Requires Special
By You Med Source (Name) Attention at Center
Important Health Problems
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Other information helpful to the child care program ____________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Signature of Health Source: _________________________________ Date: _________________________
Address: __________________________________________________ Telephone: _____________________
MS-2083
