I have have not reviewed the above information with the parent/guardian.
Physician:_______________________________________________ Date of Physical Exam: ___________________________________
Address:________________________________________________ Date This Form Completed: _______________________________
Telephone: ______________________________________________ Signature ______________________________________________
Physician Physician’s Assistant Nurse Practitioner
DATE EACH DOSE WAS GIVEN
//
//
IMMUNIZATION HISTORY: (Fill out or enclose California Immunization Record, PM-298.)
PHYSICIAN’S REPORT—CHILD CARE CENTERS
(CHILD’S PRE-ADMISSION HEALTH EVALUATION)
PART A – PARENT’S CONSENT
(TO BE COMPLETED BY PARENT)
__________________________________________, born ________________________________ is being studied for readiness to enter
(NAME OF CHILD) (BIRTH DATE)
_________________________________________ . This Child Care Center/School provides a program which extends from _____ : ____
(NAME OF CHILD CARE CENTER/SCHOOL)
a.m./p.m. to ______ a.m./p.m. , __________ days a week.
Please provide a report on above-named child using the form below. I hereby authorize release of medical information contained in this
report to the above-named Child Care Center.
__________________________________________________________ _________________
(SIGNATURE OF PARENT, GUARDIAN, OR CHILD’S AUTHORIZED REPRESENTATIVE) (TODAY’S DATE)
PART B – PHYSICIAN’S REPORT (TO BE COMPLETED BY PHYSICIAN)
Problems of which you should be aware:
Hearing: Allergies:medicine:
Vision: Insect stings:
Developmental: Food:
Language/Speech: Asthma:
Dental:
Other (Include behavioral concerns):
Comments/Explanations:
MEDICATION PRESCRIBED/SPECIAL ROUTINES/RESTRICTIONS FOR THIS CHILD:
LIC 701 (8/08) (Confidential)
1st 2nd 3rd 4th 5th
VACCINE
POLIO (OPV OR IPV)
DTP/DTaP/
DT/Td
MMR
HIB MENINGITIS
HEPATITIS B
VARICELLA
(DIPHTHERIA, TETANUS AND
[ACELLULAR] PERTUSSIS OR TETANUS
AND DIPHTHERIA ONLY)
(MEASLES, MUMPS, AND RUBELLA)
(REQUIRED FOR CHILD CARE ONLY)
(CHICKENPOX)
(HAEMOPHILUS B)
// // // // / /
// // // // / /
// //
// // //
// //
// //
SCREENING OF TB RISK FACTORS (listing on reverse side)
Risk factors not present; TB skin test not required.
Risk factors present; Mantoux TB skin test performed (unless
previous positive skin test documented).
___ Communicable TB disease not present.
STATE OF CALIFORNIA
HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
PAGE 1 OF 2
RISK FACTORS FOR TB IN CHILDREN:
* Have a family member or contacts with a history of confirmed or suspected TB.
* Are in foreign-born families and from high-prevalence countries (Asia, Africa, Central and South America).
* Live in out-of-home placements.
* Have, or are suspected to have, HIV infection.
* Live with an adult with HIV seropositivity.
* Live with an adult who has been incarcerated in the last five years.
* Live among, or are frequently exposed to, individuals who are homeless, migrant farm workers, users of street drugs, or residents in
nursing homes.
* Have abnormalities on chest X-ray suggestive of TB.
* Have clinical evidence of TB.
Consult with your local health department’s TB control program on any aspects of TB prevention and treatment.
LIC 701 (8/08) (Confidential) PAGE 2 of 2
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