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PROVIDER EVALUATION
SYMPTOMS
_____Vomiting _____Diarrhea _____Rash _____Uncontrolable Cough
_____Dark Urine _____Light Stool _____Constipation _____Eye Drainage
_____Mouth Sores _____Skin Lesions _____Lice _____Respiratory Signs
_____Jaundice _____Nose Drainage _____Fever _____Unusual Aches/Pains
_____Wheezing _____Soar Throat _____Ear Ache _____Nose Bleeds
For your information cases of ________________________________ have recently been
reported in another child attending our program.
This Child has already been excluded from the Child Care Home: YES NO
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HEALTH CARE EVALUATION
DIAGNOSIS
Is this condition communicable? YES NO
If YES, what should I be aware of?_________________________________________
Treatment? YES NO
If YES, describe:________________________________________________________
Can this child return to Day Care? YES NO
If NO, when can this child return?__________________________________________
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_______________________________________ _____________________
Health Care Provider's Signature Date
