IDENTIFYING INFORMATION
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.)
CHILD’S NAME BIRTHDATE
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
