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Health History Parent: Please complete this page prior to giving form to Health Care Provider Child’s Name:

Date of Birth:

Gender:

Parent(s)/Guardian(s):

Phone:

Primary Health Care Provider:

Phone:

Has this child had any operations (e.g. ear tubes), hospitalizations, or serious injuries? If yes, please describe, including date of occurrence:

“ No

M

“ Yes

Does this child have any significant or chronic health problems (e.g. asthma, seizures, diabetes, frequent ear infections, etc.)? “ No “ Yes If yes, please describe:

Does this child have any allergies (e.g. food, medicines, insects)? If yes, please describe, including type of reaction:

Does this child have any special dietary requirements? If yes, please describe:

“ No

“ No

“ Yes

“ Yes

Does this child use any assistive device or prosthesis (e.g. eyeglasses, hearing aid, wheelchair, artificial limb)? “ No “ Yes If yes, please describe:

Additional health information or instructions for school staff (e.g. hearing/speech issues, physical limitations, developmental challenges, medications needed at school): “ No “ Yes If yes, please describe:

Signature:

Parent or Legal Guardian Signature

Date

Reverse side to be completed by Health Care Provider Bal Swan Children’s Center • (303) 466-6308

• Fax (303) 466-1224

F


Physical Exam Health Care Provider: Please complete this page Child’s Name: Date of Last Physical Exam:

Recent Weight:

Vision Exam:

Hearing Exam:

Physical Exam: “ Normal If abnormal, please explain:

“ Abnormal

Significant Health Concerns: “ None “Developmental Delay

“ Vision

“ Reactive Airway Disease “ Hearing

“ Seizures

“ Hospitalizations

“ Diabetes

“ Operations

“ Severe Allergies

“ Other (please describe): Explain above concerns (if necessary, include instructions for school staff):

Current Medications: “ None “ Describe:

Do Medications Need to be Kept/Given at School? “ Yes “ No (If yes, a separate medication consent form must be completed.) Special Diet: “ None “ Describe:

Immunizations Up to Date?

“ Yes

“ No

(Please attach immunization record.)

Any additional information, recommendations, or restrictions?

Signature:

Office Stamp:

I attest that this child is healthy to attend Bal Swan Children’s Center and participate in routine activities, including swimming. Any concerns or exceptions are identified on this form.

(or print address, phone, and fax number)

Name of Health Care Provider: Title:

Date:

Signature of Health Care Provider:

Bal Swan Children’s Center • (303) 466-6308

• Fax (303) 466-1224

Health History and Physical Exam Form  

Health History and Physical Exam Form

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