HEALTH RECORD

Child’s Name ___________________________ Sex ______ Birthdate ______________

Address ________________________________Zip ________Phone _______________

Parents’ Names __________________________________________________________

Check illnesses child has had:

                Measles _____ German Measles _____ Chickenpox _____ Mumps _____

                Scarlet Fever _____ Strep Throat ______ Rheumatic Fever _____

What vaccinations has your child received, if any?

                DPT ____ DT ____ Hib ____ HeB ____ Polio ____ MMR _____

What, if any, reactions to the vaccinations has your child experienced? _____________

________________________________________________________________________

Allergies:  Indicate Type ___________________Drug reaction ___________

                  Contact with TB ____________

If tuberculin test given:  Date __________________ Result _______________________

Surgery, accidents, other illnesses or special problems ___________________________

________________________________________________________________________

Physical finding (includes, if tested, vision and hearing) _________________________

________________________________________________________________________

________________________________________________________________________

Comments and recommendations for teacher/director: _________________________

________________________________________________________________________

________________________________________________________________________

Parent’s Signature _________________________________Date ___________________