Return this form
30 days after the
first day of school
to Julie Forlenza.
Children's Medical Report
Print Form
Parent(s) and Pediatrician must fill in both sides completely. Once report is complete, it may be
faxed to 704.341.5422 or emailed to [email protected].
Name of Child ___________________________________________________________Birthdate_______________________
Name of Parent or Guardian ______________________________________________________________________________
Address of Parent or Guardian _____________________________________________________________________________
A. Medical History (May be completed by parent/guardian)
1. Is child allergic to anything? No________ Yes______ If yes, what?______________________________________________
______________________________________________________________________________________________________
2. Is child currently under a doctor's care? No________ Yes______ If yes, for what reason?____________________________
______________________________________________________________________________________________________
3. Is the child on any continuous medication? No________ Yes______ If yes, what? ___________________________________
______________________________________________________________________________________________________
4. Any previous hospitalizations or operations? No________ Yes______ If yes, when and what for?_____________________
______________________________________________________________________________________________________
5. Any history of significant previous diseases or recurrent illness? No________ Yes_____ Diabetes? No_____ Yes_____\_;
Convulsions? No______ Yes______; Heart Trouble No______ Yes______; Asthma No______ Yes______
If others, what/when? __________________________________________________________________________________________
6. Does the child have any physical disabilities: No________ Yes______ if yes, please describe: _____________________
___________________________________________________________________________________________________
Any mental disabilities? No________ Yes______ if yes, please describe: ________________________________________
Signature of Parent/Guardian __________________________________________ Date_______________
This section to be completed by the pediatrician:
B. Physical Examination: This examination must be completed and signed by a licensed physician, his authorized
agent currently approved by the N.C. Board of Medical Examiners (or a comparable board from bordering states),
a certified nurse practitioner, or a public health nurse meeting DEHNR standards for EPSDT program.
Height ___________% Weight _________________%
Head __________ Eyes __________Ears
__________ Nose __________Weight
Teeth __________
Height _________________%
_________________%
Throat __________ Neck __________ Heart __________ Chest __________ Abd/GU __________
Head __________ Eyes __________Ears __________ Nose __________ Teeth __________
Throat __________ Neck __________ Heart __________ Chest __________ Abd/GU __________
Results of Tuberculin
Test, ifNeurological
given: Type _________
Date __________ Normal
Abnormal__________
Ext __________
System ____________________
Skin___
__________
Should activities be limited? No _____ Yes _____ If yes, explain _____________________________________________
Ext __________ Neurological System ____________________ Skin __________ Vision __________ Hearing __________
Any other recommendations: ________________________________________________________________________
_________________________________________________________________________________________________
Developmental Evaluation: delayed _______________ age appropriate ______________
If delay, note significance and special care needed: _______________________________________________________
Date of
_________________________________________________________________________________________________
examination _________
Should activities be limited? No _____ Yes _____ If yes, explain: ____________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Date of Examination: ______________
Signature of authorized examiner/title __________________________________________ Phone # _______________
Immunization History
Name: ____________________________________ Date of Birth ______________________
Enter the date an immunization was received in the space below or attach a copy of the immunization
record. G.S. 130A-155(b) requires all child care facilities to have this information on file.
Enter date of each dose - Month/Day/Year
VACCINE
*DTP/DT
(Circle which)
#1
#2
#3
*Polio
**Hib
***Hepatitis B
*MMR
(Combined doses)
****Chicken Pox
PREVNAR
OTHER
*
**
***
****
Required by State law.
Required by State law for children born on or after 10/1/88.
Required by State law for children born on or after 7/01/94.
Required by State law for children born on or after 4/01/01.
Records Updated by:
Date Updated:
#4
#5