Children’s Medical Report Leave this field blank Children's Medical Report Name of Child Birthdate: Name of Parent or Guardian Address of Parent or Guardian A. Medical History (May be completed by parent) Is Child allergic to anything? Yes No If yes, what? Is child currently under a doctor's care? Yes No If yes, for what reason? Is the child on any continuous medication? Yes No If yes, what? Any previous hospitalizations or operations? Yes No If yes, when and for what? Any history of significant previous diseases or recurrent illnes? Yes No Diabetes Yes No Convulsions Yes No Heart Trouble Yes No Asthma Yes No If others, what/when? Signature of Parent or Guardian Start drawing Clear Done Start over Date B. Physical Examination This examination must be completed and signed by a licensed physician, his authorized agent currently approved by the N.C. Board of Medical Examiners (or a comparable board from bordering states), a certified nurse practitioner, or a public health nurse meeting DHHS standards for EPSDT program. Height (optional) Weight (optional) Head (optional) Eyes (optional) Ears (optional) Nose (optional) Teeth (optional) Throat (optional) Neck (optional) Heart (optional) Chest (optional) ABD/GU (optional) Ext (optional) Neurological System (optional) Skin (optional) Vision (optional) Hearing (optional) Results of Tuberculin Test, if given: Type (optional) Date (optional) Normal (optional) Abnormal (optional) Follow-up (optional) Developmental Evaluation: Delayed (optional) Age Appropriate (optional) If delay, note significance and special care needed: (optional) Should activities be limited? (optional) Yes No If yes, explain: (optional) Any other recommendations: (optional) Signature of authorized examiner/title Phone: (optional) Submit A place where children grow, learn and thrive. Let's team up together! Inquire Now!
