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    Medical Form Creative Hands Early Childhood Institution

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    api-532410048
    This medical form from Creative Hands Early Childhood Institution collects medical information about a student. It requests the student's name, date of birth, parent/guardian contact information, medical history including allergies and conditions, current medications, and previous hospitalizations or illnesses. A physical examination section is also included to be completed by a licensed physician with measurements, evaluations of body systems, and recommendations.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Medical Form Creative Hands Early Childhood Institution

    Uploaded by

    api-532410048
    233 views3 pages
    This medical form from Creative Hands Early Childhood Institution collects medical information about a student. It requests the student's name, date of birth, parent/guardian contact information, medical history including allergies and conditions, current medications, and previous hospitalizations or illnesses. A physical examination section is also included to be completed by a licensed physician with measurements, evaluations of body systems, and recommendations.

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    medical form creative hands early childhood institution

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    This medical form from Creative Hands Early Childhood Institution collects medical information about a student. It requests the student's name, date of birth, parent/guardian contact information, medical history including allergies and conditions, current medications, and previous hospitalizations or illnesses. A physical examination section is also included to be completed by a licensed physician with measurements, evaluations of body systems, and recommendations.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    233 views3 pages

    Medical Form Creative Hands Early Childhood Institution

    Uploaded by

    api-532410048
    This medical form from Creative Hands Early Childhood Institution collects medical information about a student. It requests the student's name, date of birth, parent/guardian contact information, medical history including allergies and conditions, current medications, and previous hospitalizations or illnesses. A physical examination section is also included to be completed by a licensed physician with measurements, evaluations of body systems, and recommendations.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 3

    Creative Hands Early Childhood Institution

    Medical Form
    Creative Hands Early Childhood Institution
    20 ½ Wayford Drive, Kingston 8
    Email: creativehandsECI@gmail.com
    Telephone: 1 (876) 531-5400
    Website: creativehandseci.weebly.com
    “Moulding small minds for a better tomorrow”

    This Medical Report should be completed for a medical doctor and return to the school. The report will be
    treated with the oath most confidentiality.

    Name of Student: ______________________________________________________________________


    Date of Birth: _________________________________________________________________________
    Name of Parent/ Guardian: ______________________________________________________________
    Address of Parent/ Guardian: _____________________________________________________________
    Contact for Parent/ Guardian: ____________________________________________________________

    Medical History (May be completed by parent)

    Is the student allergic to anything? Yes ( ) No ( )


    If yes, what? __________________________________________________________________________
    _____________________________________________________________________________________
    _____________________________________________________________________________________

    Is the student currently under a doctor's care? Yes ( ) No ( )


    If yes, for what reason? _________________________________________________________________
    _____________________________________________________________________________________
    _____________________________________________________________________________________
    Is the student on any continuous medication? Yes ( ) No ( )
    If yes, what? __________________________________________________________________________
    _____________________________________________________________________________________
    _____________________________________________________________________________________
    Any previous hospitalizations or operations? Yes ( ) No ( )
    If yes, when and for what? _______________________________________________________________
    Email: creativehandsECI@gmail.com
    Telephone: 1 (876) 531-5400
    Website: creativehandseci.weebly.com
    “Moulding small minds for a better tomorrow”
    Creative Hands Early Childhood Institution
    Medical Form
    _____________________________________________________________________________________
    _____________________________________________________________________________________
    _____________________________________________________________________________________
    _____________________________________________________________________________________
    Any history of significant previous diseases or recurrent illness? Yes ( ) No ( )
    Diabetes ( )
    Convulsions ( )
    Heart trouble ( )
    Asthma ( )
    Other: _______________________________________________________________________________
    Does the child have any physical disabilities? Yes ( ) No ( )
    If yes, please describe: __________________________________________________________________
    _____________________________________________________________________________________
    _____________________________________________________________________________________
    Any mental disabilities? Yes ( ) No ( )
    If yes, please describe: __________________________________________________________________
    _____________________________________________________________________________________
    _____________________________________________________________________________________

    Physical Examination: This examination must be completed and signed by a


    licensed physician

    Height _______________________________________________________________________________
    Weight ______________________________________________________________________________
    Head ________________________________________________________________________________
    Eyes ________________________________________________________________________________
    Ears _________________________________________________________________________________
    Nose _______________________________________________________________________________
    Teeth ________________________________________________________________________________
    Throat _______________________________________________________________________________
    Neck _______________________________________________________________________________
    Heart ________________________________________________________________________________
    Email: creativehandsECI@gmail.com
    Telephone: 1 (876) 531-5400
    Website: creativehandseci.weebly.com
    “Moulding small minds for a better tomorrow”
    Creative Hands Early Childhood Institution
    Medical Form
    Chest ________________________________________________________________________________
    Neurological System ___________________________________________________________________
    Skin ________________________________________________________________________________
    Vision _______________________________________________________________________________
    Hearing ______________________________________________________________________________
    Results of urine test ____________________________________________________________________
    _____________________________________________________________________________________
    Developmental Evaluation: delayed ________ age appropriate ___________
    If delay, note significance and special care needed; ___________________________________________
    _____________________________________________________________________________________
    _____________________________________________________________________________________
    Should activities be limited? Yes ( ) No ( )
    If yes, explain: ________________________________________________________________________
    _____________________________________________________________________________________
    _____________________________________________________________________________________
    Any other recommendations: _____________________________________________________________
    _____________________________________________________________________________________
    _____________________________________________________________________________________
    _____________________________________________________________________________________
    Date of Examination: ___________________________________________________________________
    Signature of Parent or Guardian _______________________________ Date _______________________
    Signature of Medical Doctor: _____________________________________________________________
    Stamp of Medical Doctor:

    Email: creativehandsECI@gmail.com
    Telephone: 1 (876) 531-5400
    Website: creativehandseci.weebly.com
    “Moulding small minds for a better tomorrow”

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