Pa Child Report Form – Fill Out and Use This PDF

Parent/Provider fill in this part.

	CH I LD H EALTH REPORT
	( 5 5 PA COD E § § 3 2 7 0 . 1 3 1 , 3 2 8 0 . 1 3 1 AN D 3 2 9 0 . 1 3 1 )
CHI LD’S NAME: ( LAST)	( FI RST)	PARENT/ GUARDI AN:
DATE OF BI RTH:	HOME PHONE:	ADDRESS:
CHI LD CARE FACI LI TY NAME:
FACI LI TY PHONE:	COUNTY:	WORK PHONE:

ﾆ＃I aut hor ize t he child car e st aff and m y child’s healt h pr ofessional t o com m unicat e dir ect ly if needed t o clar ify infor m at ion on t his for m about m y child.

PARENT’S SI GNATURE:

D O N OT OM I T AN Y I N FORM ATI ON

Th is for m m a y be u pda t e d by a h e a lt h pr ofe ssion a l. I n it ia l a n d da t e a n y n e w da t a . Th e ch ild ca r e fa cilit y n e e ds a copy of t h e for m .

HEALTH HI STORY AND MEDI CAL I NFORMATI ON PERTI NENT TO ROUTI NE CHI LD CARE AND DI AGNOSI S/ TREATMENT I N EMERGENCY ( DESCRI BE, I F ANY) : ﾆ＃NONE

DESCRI BE ALL MEDI CATI ON AND ANY SPECI AL DI ET THE CHI LD RECEI VES AND THE REASON FOR MEDI CATI ON AND SPECI AL DI ET. ALL MEDI CATI ONS A CHI LD RECEI VES SHOULD BE DOCUMENTED I N THE EVENT THE CHI LD REQUI RES EMERGENCY MEDI CAL CARE. ATTACH ADDI TI ONAL SHEETS I F NECESSARY. ﾆ＃NONE

CHI LD’S ALLERGI ES ( DESCRI BE, I F ANY) : ﾆ＃NONE

LI ST ANY HEALTH PROBLEMS OR SPECI AL NEEDS AND RECOMMENDED TREATMENT/ SERVI CES. ATTACH ADDI TI ONAL SHEETS I F NECESSARY TO DESCRI BE THE PLAN FOR CARE THAT SHOULD BE FOLLOWED FOR THE CHI LD, I NCLUDI NG I NDI CATI ON OF SPECI AL TRAI NI NG REQUI RED FOR STAFF, EQUI PMENT AND PROVI SI ON FOR EMERGENCI ES.

ﾆ＃NONE

I N YOUR ASSESSMENT, I S THE CHI LD ABLE TO PARTI CI PATE I N CHI LD CARE AND DOES THE CHI LD APPEAR TO BE FREE FROM CONTAGI OUS OR COMMUNI CABLE DI SEASES?

ﾆ＃YES

ﾆ＃NO I F NO, PLEASE EXPLAI N YOUR ANSWER:

complete all data.

HAS THE CHI LD RECEI VED ALL AGE APPROPRI ATE SCREENI NGS LI STED I N THE ROUTI NE PREVENTI VE HEALTH CARE SERVI CES CURRENTLY RECOMMENDED BY THE AMERI CAN ACADEMY OF PEDI ATRI CS? ( SEE SCHEDULE AT WWW.AAP.ORG)

ﾆ＃YES ﾆ＃NO

NOTE BELOW I F THE RESULTS OF VI SI ON, HEARI NG OR LEAD SCREENI NGS W ERE ABNORMAL. I F THE SCREENI NG W AS ABNORMAL, PROVI DE THE DATE THE SCREENI NG W AS COMPLETED AND

I NFORMATI ON ABOUT REFERRALS, I MPLI CATI ONS OR ACTI ONS RECOMMENDED FOR THE CHI LD CARE FACI LI TY.

VI SI ON ( subj ect ive unt il age 3 )

H EARI N G ( su bj e ct iv e u n t il a ge 4 )

LEAD

Parents may write immunization dates; health professional should verify and

RECORD D ATES OF I M M UN I ZATI ON S BELOW OR ATTACH A PH OTOCOPY OF TH E CH I LD ’S I M M UN I ZATI ON RECORD

I M M UN I ZATI ON S	DATE	DATE	DATE	DATE	DATE		COM M EN TS
H EP- B
ROTAVIRUS
DTAP/DTP/TD
HIB
PNEUMOCOCCAL
POLIO
INFLUENZA
MMR
VARICELLA
HEP-A
MENINGOCOCCAL
OTHER
MEDI CAL CARE PROVI DER:					SI GNATURE OF PHYSI CI AN, CRNP OR PHYSI CI AN’S ASSI STANT
ADDRESS:
					TI TLE:
		PHONE:			LI CENSE NUMBER:		DATE FORM SI GNED: