Physician's Report for Child Care Instructions
This form contains 100 fields organized into 20 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Birth Date | ||
| Birth Date | Date |
Please provide the child's date of birth.
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| Child Care Center/School Name | ||
| Child Care Center/School Name | Text |
Please provide the full name of the child care center or school.
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| Child's Name | ||
| Child's First Name | Text |
Please provide the child's first name.
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| Child's Last Name | Text |
Please provide the child's last name.
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| Comments/Explanations | ||
| Comments and Explanations | Text |
Provide any additional comments or explanations regarding the child's health or specific needs.
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| DTP/DTaP/DT/Td Immunization Dates | ||
| 1st DTP/DTaP/DT/Td Dose Month | Date |
Enter the month (MM) when the first dose of DTP/DTaP/DT/Td immunization was given.
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| 1st DTP/DTaP/DT/Td Dose Day | Date |
Enter the day (DD) when the first dose of DTP/DTaP/DT/Td immunization was given.
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| 1st DTP/DTaP/DT/Td Dose Year | Date |
Enter the year (YYYY) when the first dose of DTP/DTaP/DT/Td immunization was given.
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| 2nd DTP/DTaP/DT/Td Dose Month | Date |
Enter the month (MM) when the second dose of DTP/DTaP/DT/Td immunization was given.
|
| 2nd DTP/DTaP/DT/Td Dose Day | Date |
Enter the day (DD) when the second dose of DTP/DTaP/DT/Td immunization was given.
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| 2nd DTP/DTaP/DT/Td Dose Year | Date |
Enter the year (YYYY) when the second dose of DTP/DTaP/DT/Td immunization was given.
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| 3rd DTP/DTaP/DT/Td Dose Month | Date |
Enter the month (MM) when the third dose of DTP/DTaP/DT/Td immunization was given.
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| 3rd DTP/DTaP/DT/Td Dose Day | Date |
Enter the day (DD) when the third dose of DTP/DTaP/DT/Td immunization was given.
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| 3rd DTP/DTaP/DT/Td Dose Year | Date |
Enter the year (YYYY) when the third dose of DTP/DTaP/DT/Td immunization was given.
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| 4th DTP/DTaP/DT/Td Dose Month | Date |
Enter the month (MM) when the fourth dose of DTP/DTaP/DT/Td immunization was given.
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| 4th DTP/DTaP/DT/Td Dose Day | Date |
Enter the day (DD) when the fourth dose of DTP/DTaP/DT/Td immunization was given.
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| 4th DTP/DTaP/DT/Td Dose Year | Date |
Enter the year (YYYY) when the fourth dose of DTP/DTaP/DT/Td immunization was given.
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| 5th DTP/DTaP/DT/Td Dose Month | Date |
Enter the month (MM) when the fifth dose of DTP/DTaP/DT/Td immunization was given.
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| 5th DTP/DTaP/DT/Td Dose Day | Date |
Enter the day (DD) when the fifth dose of DTP/DTaP/DT/Td immunization was given.
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| 5th DTP/DTaP/DT/Td Dose Year | Date |
Enter the year (YYYY) when the fifth dose of DTP/DTaP/DT/Td immunization was given.
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| Exam Dates | ||
| Date of Physical Exam | Date |
Please provide the date of the physical examination.
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| Date Form Completed | Date |
Please provide the date this form was completed.
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| General | ||
| Button | ||
| Signature | ||
| Health Assessment | ||
| General Problems | Text |
Enter any general health problems or concerns the child has.
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| Hearing Issues | Text |
Describe any hearing problems or concerns for the child.
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| Medicine Allergies | Text |
List any known allergies the child has to medicine.
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| Vision Issues | Text |
Describe any vision problems or concerns for the child.
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| Insect Sting Allergies | Text |
List any known allergies the child has to insect stings.
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| Developmental Concerns | Text |
Describe any developmental concerns or issues for the child.
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| Food Allergies | Text |
List any known food allergies the child has.
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| Language Speech Issues | Text |
Describe any language or speech problems or concerns for the child.
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| Asthma | Text |
Provide details regarding any asthma conditions the child has.
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| Dental Concerns | Text |
Describe any dental problems or concerns for the child.
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| Other Concerns | Text |
Provide any other health-related concerns, including behavioral issues, not listed above.
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| Hepatitis B Immunization Dates | ||
| Hepatitis B 1st Dose Month | Date |
Enter the month of the first Hepatitis B immunization dose.
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| Hepatitis B 1st Dose Year | Date |
Enter the year of the first Hepatitis B immunization dose.
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| Hepatitis B 2nd Dose Month | Date |
Enter the month of the second Hepatitis B immunization dose.
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| Hepatitis B 2nd Dose Year | Date |
Enter the year of the second Hepatitis B immunization dose.
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| Hepatitis B 3rd Dose Month | Date |
Enter the month of the third Hepatitis B immunization dose.
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| Hepatitis B 3rd Dose Year | Date |
Enter the year of the third Hepatitis B immunization dose.
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| Hepatitis B 4th Dose Month | Date |
Enter the month of the fourth Hepatitis B immunization dose.
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| Hepatitis B 4th Dose Year | Date |
Enter the year of the fourth Hepatitis B immunization dose.
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| Hepatitis B 5th Dose Month | Date |
Enter the month of the fifth Hepatitis B immunization dose.
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| HIB Meningitis Immunization Dates | ||
| HIB Meningitis 1st Dose (Month/Day) | Date |
Enter the month and day of the first HIB Meningitis immunization dose.
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| HIB Meningitis 1st Dose (Year) | Date |
Enter the year of the first HIB Meningitis immunization dose.
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| HIB Meningitis 2nd Dose (Month/Day) | Date |
Enter the month and day of the second HIB Meningitis immunization dose.
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| HIB Meningitis 2nd Dose (Year) | Date |
Enter the year of the second HIB Meningitis immunization dose.
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| HIB Meningitis 3rd Dose (Month/Day) | Date |
Enter the month and day of the third HIB Meningitis immunization dose.
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| HIB Meningitis 3rd Dose (Year) | Date |
Enter the year of the third HIB Meningitis immunization dose.
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| HIB Meningitis 4th Dose (Month/Day) | Date |
Enter the month and day of the fourth HIB Meningitis immunization dose.
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| HIB Meningitis 4th Dose (Year) | Date |
Enter the year of the fourth HIB Meningitis immunization dose.
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| HIB Meningitis 5th Dose (Month/Day) | Date |
Enter the month and day of the fifth HIB Meningitis immunization dose.
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| HIB Meningitis 5th Dose (Year) | Date |
Enter the year of the fifth HIB Meningitis immunization dose.
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| HIB Meningitis Additional Dose (Month/Day) | Date |
Enter the month and day for an additional HIB Meningitis immunization dose.
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| HIB Meningitis Additional Dose (Year) | Date |
Enter the year for an additional HIB Meningitis immunization dose.
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| Medication/Restrictions | ||
| Medication and Restrictions | Text |
Provide a comprehensive list of all prescribed medications, special routines, and any other restrictions applicable to this child.
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| MMR Immunization Dates | ||
| MMR 1st Dose Date | Date |
Enter the date the first dose of the MMR (Measles, Mumps, and Rubella) vaccine was given.
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| MMR 2nd Dose Date | Date |
Enter the date the second dose of the MMR (Measles, Mumps, and Rubella) vaccine was given.
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| MMR 3rd Dose Date | Date |
Enter the date the third dose of the MMR (Measles, Mumps, and Rubella) vaccine was given.
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| MMR 4th Dose Date | Date |
Enter the date the fourth dose of the MMR (Measles, Mumps, and Rubella) vaccine was given.
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| MMR 5th Dose Date | Date |
Enter the date the fifth dose of the MMR (Measles, Mumps, and Rubella) vaccine was given.
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| MMR Additional Dose Date | Date |
Enter the date of any additional or booster dose of the MMR (Measles, Mumps, and Rubella) vaccine given beyond the fifth dose.
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| Parent/Guardian Signature Date | ||
| Signature Date | Date |
Provide the date the parent or guardian signed the consent form.
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| Physician's Information | ||
| Physician Name | Text |
Please provide the full name of the physician.
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| Physician Address | Text |
Please provide the complete mailing address of the physician.
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| Physician Telephone Number | Text |
Please provide the telephone number of the physician.
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| Physician's Review Confirmation | ||
| I have reviewed | Checkbox |
Check this box if the physician has reviewed the above information with the parent or guardian.
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| I have not reviewed | Checkbox |
Check this box if the physician has not reviewed the above information with the parent or guardian.
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| Polio (OPV or IPV) Immunization Dates | ||
| First Polio Dose Month | Date |
Enter the month for the first dose of Polio (OPV or IPV) immunization.
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| First Polio Dose Day | Date |
Enter the day for the first dose of Polio (OPV or IPV) immunization.
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| First Polio Dose Year | Date |
Enter the year for the first dose of Polio (OPV or IPV) immunization.
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| Second Polio Dose Month | Date |
Enter the month for the second dose of Polio (OPV or IPV) immunization.
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| Second Polio Dose Day | Date |
Enter the day for the second dose of Polio (OPV or IPV) immunization.
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| Second Polio Dose Year | Date |
Enter the year for the second dose of Polio (OPV or IPV) immunization.
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| Third Polio Dose Month | Date |
Enter the month for the third dose of Polio (OPV or IPV) immunization.
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| Third Polio Dose Day | Date |
Enter the day for the third dose of Polio (OPV or IPV) immunization.
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| Third Polio Dose Year | Date |
Enter the year for the third dose of Polio (OPV or IPV) immunization.
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| Fourth Polio Dose Month | Date |
Enter the month for the fourth dose of Polio (OPV or IPV) immunization.
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| Fourth Polio Dose Day | Date |
Enter the day for the fourth dose of Polio (OPV or IPV) immunization.
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| Fourth Polio Dose Year | Date |
Enter the year for the fourth dose of Polio (OPV or IPV) immunization.
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| Fifth Polio Dose Month | Date |
Enter the month for the fifth dose of Polio (OPV or IPV) immunization.
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| Fifth Polio Dose Day | Date |
Enter the day for the fifth dose of Polio (OPV or IPV) immunization.
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| Fifth Polio Dose Year | Date |
Enter the year for the fifth dose of Polio (OPV or IPV) immunization.
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| Program Schedule | ||
| Program Start Hour | Text |
Enter the hour when the program starts.
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| Program Start Minute | Text |
Enter the minute when the program starts.
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| Program End Hour | Text |
Enter the hour when the program ends.
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| Program Days Per Week | Text |
Enter the number of days per week the program operates.
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| Screening of TB Risk Factors | ||
| Risk factors not present | Checkbox |
Check this box if no TB risk factors are present, indicating a TB skin test is not required.
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| Risk factors present | Checkbox |
Check this box if TB risk factors are present, and a Mantoux TB skin test was performed (unless a previous positive skin test is documented).
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| Communicable TB disease not present | Checkbox |
Check this box if communicable TB disease is not present.
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| Signatory Title | ||
| Physician | Checkbox |
Check this box if the signatory of this form is a Physician.
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| Physician's Assistant | Checkbox |
Check this box if the signatory of this form is a Physician's Assistant.
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| Nurse Practitioner | Checkbox |
Check this box if the signatory of this form is a Nurse Practitioner.
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| Varicella Immunization Dates | ||
| Varicella 1st Dose Date | Date |
Enter the date when the 1st dose of Varicella vaccine was given.
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| Varicella 2nd Dose Date | Date |
Enter the date when the 2nd dose of Varicella vaccine was given.
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| Varicella 3rd Dose Date | Date |
Enter the date when the 3rd dose of Varicella vaccine was given.
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| Varicella 4th Dose Date | Date |
Enter the date when the 4th dose of Varicella vaccine was given.
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| Varicella 5th Dose Date | Date |
Enter the date when the 5th dose of Varicella vaccine was given.
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| Varicella 6th Dose Date | Date |
Enter the date when the 6th dose of Varicella vaccine was given.
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