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  • Medical Record

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    This medical record document contains identifying and contact information for a child patient, including their full name, address, date of birth, and phone numbers for their mother and father. It includes sections for additional medical information, the child's medical and physical history, developmental history, emotional history, any illnesses they have had or currently suffer from, and their immunization record with dates for various vaccinations. The parent(s) sign to certify the accuracy of the immunization history.

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    medical record

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    This medical record document contains identifying and contact information for a child patient, including their full name, address, date of birth, and phone numbers for their mother and father. It includes sections for additional medical information, the child's medical and physical history, developmental history, emotional history, any illnesses they have had or currently suffer from, and their immunization record with dates for various vaccinations. The parent(s) sign to certify the accuracy of the immunization history.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    34 views3 pages

    Medical Record

    Uploaded by

    api-209984912
    This medical record document contains identifying and contact information for a child patient, including their full name, address, date of birth, and phone numbers for their mother and father. It includes sections for additional medical information, the child's medical and physical history, developmental history, emotional history, any illnesses they have had or currently suffer from, and their immunization record with dates for various vaccinations. The parent(s) sign to certify the accuracy of the immunization history.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 3

    Medical Record

    Childs Full name:

    ____________________________________________________________
    Last

    First

    Middle

    Address: _________________________

    Home phone: ______________

    Date of birth:

    Age:_____________________
    ______________________

    Mother

    ____________________

    Wk Phone
    Alternate #___________

    ______________________
    Father

    ____________________

    Wk Phone
    Alternate #___________

    ADDITIONAL INFORMATION (e.g., food and medicine allergies, medications being taken)
    _____________________________________________________________
    _____________________________________________________________
    Medical:_____________________________________________________
    ____________________________________________________________
    Physical: _____________________________________________________________
    _____________________________________________________________
    Developmental: ______________________________________________
    ___________________________________________________________
    Emotional: __________________________________________________
    ___________________________________________________________

    Has your child had:


    Circle all that apply

    Does your child suffer from:


    Circle all that apply

    Measles

    Headaches

    German Measles

    Ear aches

    Chicken Pocks

    Stomach aches

    Mumps

    Colds

    Whooping cough

    Flu

    Other: _________________________

    Sore Throat
    Other _______________

    IMMUNIZATION RECORD
    (contact your local Ministry of Health for complete details before filling in this area.)
    Immunizations are up to date:
    Yes _____ No______

    Vaccines

    Dose 1

    Dose 2

    Dose 3

    Dose 4

    Dose 5

    Diphtheria/Tetanus/ Pertussis
    (DTaP, Tdap, Td)

    Booster Dose Tdap


    (Not given prior to 10 years of age)

    Polio (IPV or OPV)


    Varicella (Chickenpox)VZV or VAR
    Check here if child has had chickenpox disease
    ___________(mm/dd/yy)

    Measles/ Mumps/ Rubella


    (MMR)
    Hepatitis B (Hep B)
    Hepatitus A (Hep A)
    Haemophilus Influenzae
    Type B (Hib)
    (Only children less than 5 years)

    I certify that the above information is an accurate record of this childs immunization history.
    Parent Signature (s):
    Date: _______________________
    _________________________
    _________________________

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