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Immunization History


Name:___________________________________   Date of Birth:_____________________________

Enter the date an immunization was received in the space below or attach a copy of the immunization record.  G.S.130A-155(b) requires all child care facilities to have this information on file.

Enter date of each dose - Month/Day/Year 


 Vaccine  #1  #2  #3  #4  #5
 *DTP/DT (circle which)          
 ***Hepatitis B          
 *MMR (combined doses)          
****Chicken Pox          


*Required by State law.

      **Required by State law for children born on or after 10/1/88.

     ***Required by State law for children born on or after 7/1/94.

    ****Required by State law for children born on or after 4/1/01.


 Records Updated by:  Date Updated:



Children's Medical Report


Name of Child____________________________  Birth date______________________________

Name of Parent or Guardian ________________________________________________________

Address of Parent or Guardian ______________________________________________________

A.  Medical History (May be completed by parent)

1.  Is Child allergic to anything?  No _____  Yes ______ If yes, what? __________________


2.  Is Child currently under a doctor's care?  No _____  Yes ______ If yes, for what reason?


3.  Is the Child on any continuous medication?  No______  Yes ______  If yes, what? ______


4.  Any previous hospitalizations or operations?  No _______  Yes _______  If yes, when and

what for? _____________________________________________________________________

5.  Any history of significant previous diseases or recurrent illness? No _______ Yes _______; 

diabetes No_______ Yes ________; convulsions No_______ Yes _______; heart trouble No__

Yes ______ If others, what/when? _________________________________________________

6.  Does the child have any physical disabilities: No ______ Yes ______ If yes, please 

describe: ______________________________________________________________________

7.  Any mental disabilities? No ________ Yes _______ If yes, please describe: ____________


Signature of Parent or Guardian _____________________ 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 DEHNR standards for EPSDT program.

Height ______%  Weight _______%  Head _____  Eyes _______ Ears ______ Nose _______ Teeth ________ Throat ________

Neck _______ Heart _______ Chest ________ Abd/GU _________ Ext _________ Neurological System ________ Skin _______

Results of Tuberculin Test, if given: Type ______ date ______ Normal _______ Abnormal ______

Should activities be limited? No _______ Yes _______ If yes, explain: ______________________________________________

Any other recommendations: ______________________________________________________________________________


Signature of authorized examiner/title _________________________________ Phone # _____________________