PHYSICIAN'S REPORT-CHILD CARE CENTERS

PART A- PARENT'S CONSENT (TO BE COMPLETED BY PARENT)

Name of Child:

Birth Date:

Is being studied for readiness to enter:

This Child Care Center/School provides a program which extends:

From:

To:

Please provide a report on an above-named child using the form below. I hereby authorize the 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: Polio (OPV or IPV)

DATE EACH DOSE WAS GIVEN:

1st

2nd

3th

4th

5th

VACCINE: DTPIDTaP/DT/Td (DIPHTHERIA, TETANUS AND [ACELLULAR] PERTUSSIS OR TETANUS AND DIPHTHERIA ONLY)

DATE EACH DOSE WAS GIVEN:

1st

2nd

3rd

4th

5th

VACCINE: MMR (Measles, Mumps, and Rubella)

DATE EACH DOSE WAS GIVEN:

1st

2nd

3rd

4th

5th

VACCINE: HIB MENINGITIS (Required for Child Care only) (HAEMOPHILUS B)

DATE EACH DOSE WAS GIVEN:

1st

2nd

3rd

4th

5th

VACCINE: HEPATITIS B

DATE EACH DOSE WAS GIVEN:

1st

2nd

3rd

4th

5th

VACCINE: VARICELLA (Chickenpox)

DATE EACH DOSE WAS GIVEN:

1st

2nd

3rd

4th

5th

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 document)

Communicable TB disease not present.

Reviewed the above information with the parent/guardian.

I have

I have not

Physician:

Address:

Telephone:

Date of Physical Exam:

Date This From Completed:

Signature::

Physician

Physician's Assistant

Nurse Practitioner

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.

Your information will be encrypted.