| Doctor's Name: | |
| Phone #: | |
| Street Address: | |
| Child's Health Card #: | |
| Any allergies? (__)YES (__)NO | |
| If YES, please list allergies: | |
| Special instructions in the event of an allergic reaction: | |
| Has your child had any recent serious illness? (__)YES (__)NO | |
| If YES, please describe: | |
| Has or does your child have any known health problems? (__)YES (__)NO | |
| If YES, please describe: | |
| Does your child need regular medication for health problems? (__)YES (__)NO | |
| If YES, what and when is it given? | |
| *Please sign the permission forms, authorizing Kelly to administer the medication if needed. | |
| Communicable diseases your child has had (circle those that apply): | |
| Chicken Pox, Measles, German Measles, Mumps, Scarlet Fever, Ringworm, Tuberculosis, Polio, Hepatitis | |
| Other (please list): | |
| Is your child prone to or has your child had any of the following? (circle those that apply): | |
| Bronchitis, Asthma, Whooping Cough, Headaches, Skin Rashes (not including diaper rash), Urinary Problems, Ear Aches, Ear Infections, Diabetes, Convulsions, Heart Trouble, Fainting Spells | |
| Other (please list): | |
| Are there any indications of vision or hearing problems? (__)YES (__)NO | |
| Does your child have any mental or physical disabilities? (__)YES (__)NO | |
| If YES, please describe: | |
Kelly's Home Childcare
www.geocities.com/kellyshomecc
