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SECTION I - TO BE COMPLETED BY PARENT(S) |
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Child’s Name (Last) (First)
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Gender Male Female |
Date of Birth
/ /
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Parent/Guardian Name
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Home Telephone Number
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Work Telephone/Cell Phone Number
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Parent/Guardian Name
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Home Telephone Number
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Work Telephone/Cell Phone Number
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I give my consent for my child’s Health Care
Provider and Child Care Provider/School Nurse to discuss the
information on this form.
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Signature/Date
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This form may be released to WIC.
Yes No |
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SECTION II - TO BE COMPLETED BY HEALTH CARE PROVIDER |
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Date of Physical Examination:
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Results of physical examination normal? Yes
No |
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Weight(must
be taken within 30 days for WIC) |
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Height
(must be taken within 30 days for WIC) |
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Head Circumference
(if <2 Years) |
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Blood Pressure
(if >3 Years) |
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IMMUNIZATIONS |
Immunization Record Attached Date Next
Immunization Due: |
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MEDICAL CONDITIONS |
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Chronic Medical Conditions/Related Surgeries
· List medical
conditions/ongoing surgical concerns:
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None
Special Care Plan Attached
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Comments
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Medications/Treatments
· List medications/treatments:
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None
Special Care Plan Attached
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Comments
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Limitations to Physical Activity
· List limitations/special
considerations:
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None
Special Care Plan Attached
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Comments
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Special Equipment Needs
· List items necessary for
daily activities
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None
Special Care Plan Attached
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Comments
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Allergies/Sensitivities
· List allergies:
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None
Special Care Plan Attached
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Comments
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Special Diet/Vitamin & Mineral Supplements
· List dietary specifications:
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None
Special Care Plan Attached
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Comments
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Behavioral Issues/Mental Health Diagnosis
· List behavioral/mental
health issues/concerns:
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None
Special Care Plan Attached
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Comments
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Emergency Plans
· List emergency plan that
might be needed and the sign/symptoms to watch for:
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None
Special Care Plan Attached
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Comments
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PREVENTIVE HEALTH SCREENINGS |
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Type Screening |
Date Performed |
Record Value |
Type Screening |
Date Performed |
Note if Abnormal |
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Hgb/Hct |
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Hearing |
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Lead: Capillary Venous |
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Vision |
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TB (mm of Induration) |
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Dental |
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Other: |
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Developmental |
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Other: |
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Scoliosis |
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Name of Health Care Provider (Print)
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Signature/Date
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