PHYSICIAN'S REPORT—CHILD CARE CENTERS

PHYSICIAN'S REPORT—CHILD CARE CENTERS
STATE OF CALIFORNIA
HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
(CHILD'S PRE-ADMISSION HEALTH EVALUATION)
PART A – PARENT'S CONSENT (TO BE COMPLETED BY PARENT)
Name of Child:
Birth Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name of Child Care Center/School:
This Child Care Center/School provides a program which extends from

Hour Minutes

AM/PM Option

to

Hour Minutes

AM/PM Option
Days a Week
How many days in 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/Authorized Representative:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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.)

Rows	1st	2nd	3rd	4th	5th
POLIO (OPV OR IPV)
(DIPHTHERIA, TETANUS AND DTP/DTaP/ [ACELLULAR] PERTUSSIS OR TETANUS DT/Td AND DIPHTHERIA ONLY)
(MEASLES, MUMPS, AND RUBELLA) MMR
(REQUIRED FOR CHILD CARE ONLY) HIB MENINGITIS (HAEMOPHILUS B)
HEPATITIS B
VARICELLA (CHICKENPOX)

SCREENING OF TB RISK FACTORS (listing on reverse side)
reviewed the above information with the parent/guardian.
Physician:
Date of Physical Exam:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address:
Date This Form Completed:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Telephone:
Format: (000) 000-0000.
Signature
LIC 701 (8/08) (Confidential)
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