PARENT please complete AND SIGN
Child’s Name:_______________________________________________________ Birthdate: _____________________
Allergies: ‰ None or Describe___________________________________________________________________________________________
Type of Reaction ____________________________________________________________________________________________________ Diet: ‰ Breast Fed ‰ Formula _______________________ ‰Age Appropriate
‰Special Diet ________________________________________________________________________________________________
Sleep: Your health care provider recommends that all infants less than 1 year of age be placed on their back for sleep.
‰ Preventive creams/ointments/sunscreen may be applied as requested in writing by parent unless skin is broken or bleeding.
I, ________________________________________ give consent for my child’s care health provider, school child care or camp personnel to
discuss my child’s health concerns. My child’s health provider may fax this form (& applicable attachments) to my child’s school, child care
or camp personnel. FAX #: _____________________________ DATE: _____________________________

Parent/Guardian Signature___________________________________________________________________
HEALTH CARE PROVIDER: Please Complete After Parent Section Completed
Date of Last Health Appraisal: _____________________________ Weight @ Exam: _______________________________________
Physical Exam: ‰ Normal ‰ Abnormal (Specify any physical abnormalities)_____________________________________________________
Allergies: ‰ None or Describe__________________________ Type of Reaction __________________________________________________
6LJQLÀFDQW+HDOWK&RQFHUQV ‰Severe Allergies ‰Reactive Airway Disease ‰Asthma ‰Seizures ‰Diabetes ‰Hospitalizations
‰Developmental Delays ‰Behavior Concerns ‰Vision ‰Hearing ‰Dental ‰Nutrition ‰ Other ________________________________ Explain above concern (if necessary, include instructions to care providers): ______________________________________________________ Current Medications/Special Diet: ‰ None or Describe ______________________________________________________________________
Separate medication authorization form is required for medications given in school, child care or camp For Fever Reducer or Pain Reliever (for 3 consecutive days without additional medical authorization) PLEASE CHOOSE ONE PRODUCT
‰Acetaminophen (Tylenol) may be given for pain or fever over 102 degrees every 4 hours as needed 'RVHBBBBBBBBBBBBBBBBBBBBRUVHHWKHDWWDFKHGDJHDSSURSULDWHGRVDJHVFKHGXOHIURPRXURIÀFH OR ‰Ibuprofen (Motrin, Advil) may be given for pain or for fever over 102 degrees every 6 hours as needed
'RVHBBBBBBBBBBBBBBBBBBBBRUVHHWKHDWWDFKHGDJHDSSURSULDWHGRVDJHVFKHGXOHIURPRXURIÀFH Immunizations: ‰Up-to-Date ‰ See attached immunization record ‰Administered today: _____________________________________________
Health Care Provider: Complete if Appropriate
** Height @ Exam _____ ** B/P _____ **Head Circumference (up to 12 months) _______ **
** HCT/HGB _____ ** Lead Level
‰Not at risk or Level _____
‰Not at risk or Test Results ‰ Normal ‰ Abnormal
**Screenings Performed: ‰Vision: ‰Normal ‰Abnormal ‰Hearing: ‰Normal ‰Abnormal ‰Dental: ‰Normal ‰Abnormal-
Recommended Follow-up________________________________________________________________________________________
Provider Signature
Next Well Visit: ‰ Per AAP guidelines* or ‰ Age__________ This child is healthy and may participate in all routine activities in school sports, child care or camp SURJUDP$Q\FRQFHUQVRUH[FHSWLRQVDUHLGHQWLÀHGRQWKLVIRUP _____________________________________________________ Signature of Health Care Provider (certifying form was reviewed) Date: _______________ The Colorado Chapter of the American Academy of Pediatrics (AAP) and Healthy Child Care Colorado have approved this form. 04/07*The AAP recommends that children from 0-12 years have health appraisal visits at: 2, 4, 6, 9, 12, 15, 18 and 24 months, and age 3, 4, 5, 6, 8, 10 and 12 years.
Copyright 2007 Colorado Chapter of the American Academy of Pediatrics

Source: http://www.ckcs.net/preschool-images/info_copy/health_form2012.pdf


STABILIZED FOLIC ACID VITAMIN FOR THE REDUCTION OF EXCESS SLUDGE IN SEWAGE TREATMENT PLANTS Jörg Strunkheide, Dr. Ing. (Sankt Augustin, Germany) Folic acid sources and medical application Vitamins are essential nutritional compounds that contribute to a variety of functions, includingmetabolic maintenance and cell growth /1/. Each vitamin has particular roles that cannot befulfilled b

Health services staff development

GORHAM SCHOOL DEPARTMENT ALLERGY PROTOCOL HEALTH SERVICES STAFF DEVELOPMENT 1. Prior to the beginning of the school year, all staff, including food service, transportation, custodial, and maintenance staff will be trained by the school nurse about the following topics: • OSHA standard for blood borne pathogens • General first aid procedures • Emergency cards, confidentiality

Copyright © 2014 Articles Finder