Children`s Medical Report

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Children`s Medical Report
LearningTime Achievement Center
P.O. Box 1685
Fuquay Varina, NC 27526
(919)-567-1234
www.learningtimeinc.com
Children’s Medical Report
Child’s Name: ___________________________________________ Date of Birth: ______________
(Last)
(First)
(MI)
Address _________________________________________________________ Zip Code __________
Child’s Legal Guardian(s) _____________________________________________________________
Address _________________________________________________ Home Phone ______________
Employer ________________________________________________ Work Phone _______________
E-Mail __________________________________________________ Cell Phone ________________
Medical History (May be completed by parent)
1. Does the child have any known allergies? No ____ Yes ____
Explain: ______________________________________________________________________
2. Is the child currently under a doctor’s care? No ____ Yes ____
Explain: ______________________________________________________________________
3. Is the child on any continuous medication? No ____ Yes ____
Explain: ______________________________________________________________________
4. Any previous hospitalizations or operations? No ____ Yes ____
Explain: ______________________________________________________________________
5. Any history of significant previous diseases or recurrent illness? No ____ Yes ____
Diabetes? No ____ Yes ____; Convulsions? No ____ Yes ____; Heart Trouble? No ____ Yes ____
Explain: ______________________________________________________________________
6. Does the child have any physical disabilities? No ____ Yes ____
Explain: ______________________________________________________________________
7. Does the child have any mental disabilities? No ____ Yes ____
Explain: ______________________________________________________________________
8. Does the child have any behavioral or emotional disorders? No ____ Yes ____
Explain: ______________________________________________________________________
9. Does the child have any known learning disabilities? No ____ Yes ____
Explain: ______________________________________________________________________
I give LearningTime permission to administer the following as needed:
Diaper Rash Cream ____
Vaseline ____ Sunscreen ____ Antibiotic ointment ____ Hydrogen Peroxide ____ Bug Spray ____
Additional Comments: ________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
______________________________________________________
Signature of Parent/Guardian
_____________________
Date

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