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STATE OF CALIFORNIA
HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
PHYSICIAN’S REPORT—CHILD CARE CENTERS
(CHILD’S PRE-ADMISSION HEALTH EVALUATION)
PART A – PARENT’S CONSENT
(TO BE COMPLETED BY PARENT)
(NAME OF CHILD)
, born
(BIRTH DATE)
is being studied for readiness to enter
(NAME OF CHILD CARE CENTER/SCHOOL)
. This Child Care Center/School provides a program which extends from :
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:
IMMUNIZATION HISTORY: (Fill out or enclose California Immunization Record, PM-298.)
VACCINE
DATE EACH DOSE WAS GIVEN
1st 2nd 3rd 4th 5th
POLIO (OPV OR IPV)
/ /
/
/
/
/
(DIPHTHERIA, TETANUS AND
[ACELLULAR] PERTUSSIS OR TETANUS
AND DIPHTHERIA ONLY)
/ / / / / / / / / /
MMR
(MEASLES, MUMPS, AND RUBELLA)
/ / / /
HIB MENINGITIS
(REQUIRED FOR CHILD CARE ONLY)
(HAEMOPHILUS B)
/ / / /
/ / / / / /
(CHICKENPOX)
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
pre
vious positive skin test documented).
Communicable TB disease not present.
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
LIC 701 (8/08) (Confidential)
