G. A. Preschool
6725 HWY 152 E. Rockwell, NC 28138
PH 704.279.6683 FAX 704.279.6192
Student Medical Report (to be completed by Parent)
2010/2011
Name of Child ___________________________________________________________ DOB ____________________________
Address__________________________________________________ City_____________________ State ____ Zip __________
Parent or Guardian_______________________________________________________ Phone ____________________________
Family Physician _____________________________________City _________________________Phone __________________
Medical History (to be completed by Parent)
1. Allergies
 No  Yes Please list: _____________________________________________________________________
2. Asthma
 No  Yes List medication: _________________________________________________________________
3. Diabetes
 No  Yes List medication: _________________________________________________________________
4. Chicken Pox  No  Yes Disease date:
5. Is the child on any continuous medication?  No  Yes If yes, what? _____________________________________________
6. Does the child have any physical or mental disabilities:  No  Yes If yes, please describe:
_________________________________________________________________________________________________________
7. Any Previous Hospitalizations or Operations?  No  Yes If yes, when and for what?
_________________________________________________________________________________________________________
Parent/Guardian Signature: ___________________________________________________ Date: __________________________
*********************************************************************************************************
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 boarding states), a certified nurse practitioner, or public health nurse
meeting DEHNR standards for EPSDT program.
Height (inches) __________ Weight (lbs) __________
Head __________ Eyes __________Ears __________ Nose __________ Teeth __________
Throat __________ Neck __________ Heart __________ Chest __________ Abd/GU __________
General Appearance: Good __________ Fair __________ Poor __________
Ext __________ Neurological System _______________ Skin __________
Results of Tuberculin Test, if given: Type __________ Date __________ Normal ______ Abnormal ______
Should activities be limited?  No  Yes If yes, explain:
_________________________________________________________________________________________________________
Any other recommendations: _________________________________________________________________________________
Date of Examination: ______________________
Signature of Authorized Examiner/Title: ____________________________________________
Phone # __________________________
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G. A. Preschool
6725 HWY 152 E. Rockwell, NC 28138
PH 704.279.6683 FAX 704.279.6192
Immunization Record
2010/2011
Name of Child: __________________________________________________________________________
DOB: _________________ Date of Enrollment: (child’s first day of school) _______________________________
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 childcare facilities to have this information on file.
Enter date of each dose – Month/Day/Year
Required Immunizations
#1 Date
#2 Date
#3 Date
#4 Date
#5 Date
DTP or DT
Diphtheria, Tetanus,
Pertussis
Polio
MMR
Measles, Mumps,
Rubella
(combined doses)
Hep B
Hepatitis B
Hib
Haemophilus
influenza type B
Varicella
Chickenpox
Other
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 7/1/94
****Required by State Law for children born on or after 4/1/01
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