Teresas Daycare

Annual Childs Health Assessment

Childs Name ____________________________________________
Date of Birth ______________
Todays Date _____________________ Date of Enrollment ______________
Please check all that apply and list any health information needed to care for your child.
Any known allergies to: NO
YES
If yes, please list:
Medications
___ ___
_________________________________________________
Foods sensitivities
___ ___
_________________________________________________
Other
___ ___
_________________________________________________
Any chronic illnesses
or medical conditions:
Asthma
Diabetes
Seizures
Heart Problems

:
NO
___
___
___
___

YES
___
___
___
___

Any additional health information not listed above:

_____________________________________________________________________
Any routine medications your child is
taking:_________________________________________________________________
_____________________________________________________________________
Any instructions for your childs daily care:
_____________________________________________________________________
_____________________________________________________________________
Date of last physical exam. _______________ Date of last dental exam. _______________
Name of childs Medical Provider:
______________________________________________________
Address: _______________________________
Phone #: ____________________________
Name of childs Dentist ________________________________________________
Address: _______________________________
Phone #: ___________________________

*Signature_______________________________
Date: _______________________