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Health Information |
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Check if not |
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Applicable |
| Allergies(foods,
medications& environmentl) and precautions, reactions and treatment: |
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| Medications,
food supplements, modified diet currently being administered: |
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| Chronic Physical
Problems: |
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| History of
Hospitalization: |
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| History of any
diseases child has had: |
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| Any additional
health information that I should know about: |
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Immunization Record |
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Either fill in the blanks or provide me
with a copy of immunization record |
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Indicate date of shot by entering month/day/year
for each one received |
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| Immunization |
Dose1 |
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Dose2 |
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Dose3 |
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Dose4 |
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Dose 5 |
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| DPT |
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| Hep B |
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| HIB |
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| MMR |
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| Polio |
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| Varcella |
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| PCV |
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| DPT |
Diphtheria, Pertussis, Tetanus |
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| Hep B |
Hepatitia B |
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| HIB |
Haemophiles Influenza tybe b |
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| MMR |
Measles, Mumps, Rubella |
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| Polio |
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| Varcella |
Chicken Pox |
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| PCV |
Pneumococcal |
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| ___________________________________________ |
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_________________________________ |
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| Parent/Guardian
Signature |
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Date |
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