General Health Appraisal for enrollment in Child Care

General Health Appraisal for enrollment in Child Care
(To be Completed by a Health Care Professional)
Child’s Name: _________________________________________ Birth Date: ____________
Health History & Medical Information pertinent to routine child care & emergencies:
______ None
______ Yes (Please describe):
Special diet:
____________________________________________________________
Allergies:
____________________________________________________________
Type of reaction:
____________________________________________________________
Current medications:
____________________________________________________________
Describe any recurrent health problem (such as asthma, seizures, ear infections, diabetes, etc.)
illness, hospitalization, or concerns with development.
______ None
______ Please describe
_________________________________________________________________________________________
Comments: (include instructions to the child card providers(s)
_________________________________________________________________________________________
Date of most recent examination of child (within the last 12 months): ______________________________
Weight __________
Height: __________
Vision: __________
Hearing: __________
Dental Screening: __________
Health Care Provider Name: ______________________________________ Phone #: ________________
Health Care Provider Signature: ___________________________________ Date:
________________
Health Care Provider Stamp
I ________________________________________ give consent for my child’s health care provider and
First United Methodist Church MMO provider to discuss my child’s health concerns.
Parent/Guardian Name: ___________________________________________________________________
Signature: ________________________________________________________ Date: _________________
GENERAL HEALTH APPRAISAL FORM
PARENT please complete AND SIGN
Child’s Name:_______________________________________________________ Birthdate: _____________________
Allergies: q None or Describe___________________________________________________________________________________________
Type of Reaction ____________________________________________________________________________________________________
Diet: q Breast Fed q Formula _______________________ qAge Appropriate
qSpecial Diet ________________________________________________________________________________________________
Sleep: Your health care provider recommends that all infants less than 1 year of age be placed on their back for sleep.
q 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: q Normal q Abnormal (Specify any physical abnormalities)_____________________________________________________
Allergies: q None or Describe__________________________ Type of Reaction __________________________________________________
Significant Health Concerns: qSevere Allergies qReactive Airway Disease qAsthma qSeizures qDiabetes qHospitalizations
qDevelopmental Delays qBehavior Concerns qVision qHearing qDental qNutrition q Other ________________________________
Explain above concern (if necessary, include instructions to care providers): ______________________________________________________
Current Medications/Special Diet: q 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
OR
qAcetaminophen (Tylenol) may be given for pain or fever over 102 degrees every 4 hours as needed
Dose ____________________ or see the attached age-appropriate dosage schedule from our office
qIbuprofen (Motrin, Advil) may be given for pain or for fever over 102 degrees every 6 hours as needed
Dose ____________________ or see the attached age-appropriate dosage schedule from our office
Immunizations: qUp-to-Date q See attached immunization record qAdministered today: _____________________________________________
Health Care Provider: Complete if Appropriate
**ONLY REQUIRED BY EARLY HEAD START AND HEAD START PROGRAMS PER STATE EPSDT SCHEDULE**
** Height @ Exam _____ ** B/P _____ **Head Circumference (up to 12 months) _______ **
** HCT/HGB _____ ** Lead Level qNot at risk or Level _____
**TB qNot at risk or Test Results q Normal q Abnormal
**Screenings Performed: qVision: qNormal qAbnormal qHearing: qNormal qAbnormal qDental: qNormal qAbnormalRecommended Follow-up________________________________________________________________________________________
Provider Signature
Next Well Visit: q Per AAP guidelines* or q Age__________
This child is healthy and may participate in all routine activities in school sports, child care or camp
program. Any concerns or exceptions are identified on this form.
Office Stamp
Or write Name, Address, Phone, #
_____________________________________________________
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
Certificate of Immunization
6 CCR 1009—The Infant Immunization Program and Immunization of Students Attending School
Schools shall have on file an official Certificate of Immunization for every student enrolled.
COLORADO LAW REQUIRES THAT THIS FORM BE COMPLETED FOR EACH STUDENT ATTENDING COLORADO SCHOOLS
Name_________________________________________________________________ Date of Birth _______________________________________
Parent/Guardian __________________________________________________________________________________________________________
COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT—CERTIFICATE OF IMMUNIZATION
Hep B
Vaccine
Hepatitis B
DTaP
Diphtheria, Tetanus, Pertussis (pediatric)
Tdap
Tetanus, Diphtheria, Pertussis
Hib
Haemophilus influenzae type b
PCV
Pneumococcal Conjugate
DT
Diphtheria, Tetanus (pediatric)
Td
Tetanus, Diphtheria
IPV/OPV
Measles, Mumps, Rubella
Mumps
Mumps
Measles
Measles
Rubella
Rubella
Varicella
Chickenpox
HPV
Human Papillomavirus
MCV4/MPSV
4
Meningococcal
Flu
Influenza
Hep A
Titer Date
Polio
MMR
Rota
Enter the month, day and year each immunization was given
Provider Documentation Date of Disease Positive Screen Date
______________________________ _____________________________
Vaccines recorded below this line are recommended. Recording of dates is encouraged.
Rotavirus
Hepatitis A
Other
THIS SECTION CAN BE COMPLETED BY CHILD CARE/SCHOOL/HEALTH CARE PROVIDER
 A) Child Care Up to Date
Up to date through 6 months of age for Colorado School Immunization Requirements
 B) Child Care Up to Date
Up to date through 18 months of age for Colorado School Immunization Requirements
 C) Child Care/Pre-school/Pre-K*
Up to date for Child Care/Pre-School/Pre-K for Colorado School Immunization Requirements
 D) Complete for K–5th Grade
Up to date for K–5th Grade for Colorado School Immunization Requirements
______________________________________________________________
Update Signature
Date
Update Signature
Date
Update Signature
Date
Update Signature
Date
______________________________________________________________
______________________________________________________________
______________________________________________________________
* If age 4 years and fulfills Requirements for Pre-School & Kindergarten, check BOTH Boxes C and D.
CDPHE-IMM CI RC Rev. 1/16
Name_________________________________________________________________ Date of Birth _______________________________________
Parent/Guardian __________________________________________________________________________________________________________
STATEMENT OF EXEMPTION TO IMMUNIZATION LAW
(DECLARACIÓN RESPECTO A LAS EXENCIONES DE LA LEY DE VACUNACIÓN)
IN THE EVENT OF AN OUTBREAK, EXEMPTED PERSONS MAY BE SUBJECT TO EXCLUSION FROM SCHOOL AND TO QUARANTINE.
SI SE PRESENTA UN BROTE DE LA ENFERMEDAD, ES POSIBLE QUE A LAS PERSONAS EXENTAS SE LES PONGA EN CUARENTENA O SE LES EXCLUYA DE LA ESCUELA.
MEDICAL EXEMPTION: The physical condition of the above named person is such that immunization would endanger life or health or is medically
contraindicated due to other medical conditions.
EXENCIÓN POR RAZONES MÉDICAS: El estado de salud de la persona arriba citada es tal que la vacunación significa un riesgo para su salud
o incluso su vida; o bien, las vacunas están contraindicadas debido a otros problemas de salud.
Medical exemption to the following vaccine(s):
La exención por razones médicas aplica a la(s) siguiente(s) vacuna(s):
 Hep B  DTaP  Tdap  Hib  IPV  PCV  MMR  VAR
Signed (Firma) _______________________________________________________________
Physician (Médico)
Date (Fecha) ______________________________
RELIGIOUS EXEMPTION: Parent or guardian of the above named person or the person himself/herself is an adherent to a religious belief opposed
to immunizations.
EXENCIÓN POR MOTIVOS RELIGIOSOS: El padre o tutor de la persona arriba citada, o la persona misma, pertenece a una religión que se
opone a la inmunización.
Religious exemption to the following vaccine(s):
Exención por motivos religiosos de la(s) siguiente(s) vacuna(s):
 Hep B  DTaP  Tdap  Hib  IPV  PCV  MMR  VAR
Signed (Firma) _______________________________________________________________
Parent, guardian, emancipated student/consenting minor
(Padre, tutor, estudiante emancipado o consentimiento del menor)
Date (Fecha) ______________________________
PERSONAL EXEMPTION: Parent or guardian of the above named person or the person himself/herself is an adherent to a personal belief opposed
to immunizations.
EXENCIÓN POR CREENCIAS PERSONALES: Las creencias personales del padre o tutor de la persona arriba citada, o la persona misma, se
oponen a la inmunización.
Personal exemption to the following vaccine(s):
Exención por creencias personales de la(s) siguiente(s) vacuna(s):
 Hep B  DTaP  Tdap  Hib  IPV  PCV  MMR  VAR
Signed (Firma) _______________________________________________________________
Parent, guardian, emancipated student/consenting minor
(Padre, tutor, estudiante emancipado o consentimiento del menor)
Date (Fecha) ______________________________