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JACK & JILL COMMUNITY PRESCHOOL ******** MEDICAL REPORT ******** (To be completed by your child’s physician prior to the first day of school and returned to the Parent Leader.) Child’s Name: ___________________________________ Birthdate:___/___/___ Address: ___________________________________ Age: _____Yrs. ___ Mos.___ ___________________________________ TO BE COMPLETED BY PHYSICIAN: 1) Significant physical findings:______________________________________________ ________________________________________________________________________ Recommended medications:___________________________________________ __________________________________________________________________ ________________________________________________________________________ Recommendations for physical education. Please circle one of the following:
4. Complete the following by giving dates of immunizations: DTP (3 or more) ___________ ___________ ___________ POLIO (3 or more) ___________ ___________ ___________ MEASLES ___________ MUMPS ___________ RUBELLA ___________ HIB _________ _________ _________ HEP B (3 doses) ___________ ___________ ___________ _________________________________________________________ ____________ (physician’s signature) (date) |
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