2011-2012 Afterschool Program Medical Form
Medicaid # _______________________ Medical Plan/Ins. ____________________ ID/Policy # _____________
If Medical Plan/Insurance, full mailing address ___________________________________________________
EMERGENCY CONTACTS
Three people who will be responsible for the child if the parent or guardian is not available:
#1 Name ______________________________ Relationship ______________ Phone ___________________
#2 Name ______________________________ Relationship ______________ Phone ___________________
#3 Name ______________________________ Relationship ______________ Phone ___________________
IMMUNIZATION HISTORY (This is a record of date of basic immunizations and recent boosters)
DPT SERIES ________________________________ BOOSTER _________________________________
POLIO OPV (SABIN) __________________________ BOOSTER _________________________________
TETANUS BOOSTER __________________________ MEASLES VACCINE (LIVE) _____________________
GERMAN MEASLES (RUBELLA) _________________ TUBERCULIN TEST __________________________
MUMPS VACCINE (LIVE _______________________
ALLERGIES PREVIOUS ILLNESSES (Specify dates)
PENICILLIN _________________________________ HAY FEVER _________________________________ INSECT STINGS
______________________________ CHICKEN POX _______________________________
TUBERCULOSIS _____________________________ MUMPS ___________________________________
RHEUMATIC FEVER __________________________ OTHER DRUGS _____________________________
CHRONIC OR RECURRENT ILLNESSES
ASTHMA ________________________________________ SEIZURES __________________________________
BRONCHITIS _____________________________________ HEART DISEASE _____________________________
DIABETES _________________________________________ SICKLE CELL DISEASE _______________________
EAR INFECTIONS _________________________________ COLDS _____________________________________
URINARY TRACT INFECTIONS _________________________ OTHER __________________________________
HEALTH EXAMINATION (Must Be Filled Out By A Licensed Physician.)
Height _____ Ft _____ In. Weight _______ Lbs. Vision L20/______ R20/_____ Blood Pressure __________
Please mark any abnormalities found in the following:
Teeth‐gums ______________ Abdomen ______________ Extremities _____________ Lungs _____________
Neck ______________ Back/Spine ________________ Skin _____________ Cardiovascular ______________
Do you have any special food restrictions or allergies (such as dietary needs, religious concerns, or others):
_______________________________________________________________________________________________________
Please list any limitations for activities:
_______________________________________________________________________________________________________
I certify that the medical history of the child on this form is correct, and that the person herein described has permission
to engage in all activities, except the ones noted above.
Physician’s Signature Clinic Name Address Telephone Date of Examination
Physician’s Stamp