PHYSICIAN'S REPORT-CHILD CARE CENTERS

(CHILD'S PRE-ADMISSION HEALTH EVALUATION)

Please correct the errors described below.

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

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

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.

PART B - PHYSICIAN'S REPORT (TO BE COMPLETED BY PHYSICIAN)

IMMUNIZATION HISTORY: (Fill out or enclose California Immunization Record, PM-298.)

VACCINE: Polio (OPV or IPV)

DATE EACH DOSE WAS GIVEN:

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

DATE EACH DOSE WAS GIVEN:

VACCINE: MMR (Measles, Mumps, and Rubella)

DATE EACH DOSE WAS GIVEN:

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

DATE EACH DOSE WAS GIVEN:

VACCINE: HEPATITIS B

DATE EACH DOSE WAS GIVEN:

VACCINE: VARICELLA (Chickenpox)

DATE EACH DOSE WAS GIVEN:

SCREENING OF TB RISK FACTORS (listing on reverse side)

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.

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