Check any special medical conditions that your child may have:
_____ Food allergies-specify please:
_____ Non food allergies-specify please:
Circle all that apply: Asthma Diabetes Epilepsy/seizure disorder Cerebral palsy/motor disorder
Gastrointestinal or feeding concerns including special diet and suppliments Emotional/behavior disorder including ADD or ADHD
Triggers that may cause problems-specify please:
Signs and symptoms to watch for-specify please:
Steps the child care provider should follow:
If medications are necessary, a copy of the "authorization to administer medication" form shoudl be attached to this form.
When to call parents regarding symptoms or failure to respond to treatment:
When to consider that the condition requires emergency medical care or reassessment:
Additional information that may be helpful to your child care provider:
Signature:______________________________________
Date signed: ____________________________
Review dates: __________ __________ ___________ ____________ ___________ ___________
(A review of this information to occure every six months or when additional information is necessary.)