Physical Form for Child in Day Care   Exam Date _________________
To Be Completed By Physician, PA or NP

Child’s Name _______________________________________________________ D.O.B.__________________

Health Specifics      Comments     

1) Are there allergies (Specify)? Yes_____  No _____   ________________________________________

2) Is medication regularly taken? Yes _____ No _____  _________________________________________
   (Specify Drug & Condition)

3) Will medication(s) need to be Yes _____ No _____  _________________________________________
  administered while in day care?  (If Yes, additional forms will be required-please see day care office)

3) Is a special diet required?  Yes _____ No _____  _________________________________________
  (Specify Diet & Condition)

4) Are there any hearing, visual or Yes _____ No _____  _________________________________________
   dental conditions that require
   special attention?   ___________________________________________________________

5) Are there any medical or   Yes _____ No _____  _________________________________________
  developmental conditions that
  require special attention?  ___________________________________________________________

6) Does Child have an IEP?  Yes _____ No _____  _________________________________________
  (If yes, please attach copy)

Summary of Physical Exam  (including special recommendations to Day Care Provider)  

_____________________________________ ______________________________________________________

_____________________________________ ______________________________________________________

_____________________________________ ______________________________________________________

Physician Signature
On the basis of my findings as indicated above and on my knowledge of the above named child, I find that

s(he) is free from contagious and communicable disease: Yes _____ No _____

s(he) is able to participate in day care: Yes _____ No _____

_________________________________ _____________________________________________________
 Signature     Address

_________________________________ _____________________________________________________
 Name (Please Print)    Address Cont’d.   Phone

***Please attach a copy of the child’s immunization record***