Iowa Child Care Infant, Toddler, Preschool Age – Child Health Exam Form HEALTH PROFESSIONAL COMPLETE THIS PAGE 1

Allergies

Child’s Name: _____________________________

Environmental: Medication: Food: Insects: Other:

Birthdate:

Age today:

Date of Exam:_____________ Height/Length: Weight:

Immunization: May attach a copy of Iowa Department of

Head Circumference-for children age 2 yr and under:

Public Health Immunization Certificate

Blood Pressure-start @ age 3 yr:

DtaP/DTP/Td

MMR

Hgb or Hct-anytime between 6-9 mo:

Hepatitis B

Pneumococcal

HIB

Varicella

Polio

Other

Blood Lead Level-start @ 12 mo: Sensory Screening:

Influenza

Vision: Right eye ________ Left eye _________

TB testing (only for high-risk child)

Hearing: Right ear ________ Left ear _________

Medication: Health professional authorizes the child may

Tympanometry (may attach results)

receive the following medications while at child care or preschool: (include over-the-counter and prescribed)

Developmental Screening 2 :

Medication Name Cough medication Diaper crème: Fever or Pain reliever: Sunscreen: Other

Developmental screening results: Autism screening results: Psychosocial/behavioral results Developmental Referral Made Today: Yes

No

Exam Results: (n = normal limits) otherwise describe HEENT Oral/Teeth Oral Health/Dental Referral Made Today:

Yes

No

Heart

Dosage

Other Medication should be listed with written instructions for use in child care.

Referrals made: Referred to hawk-i today 1-800-257-8563 Other: _________________________________

Lungs

Health Provider Assessment Statement:

Stomach/Abdomen

The child may participate in developmentally appropriate child care/preschool with NO health-related restrictions.

Genitalia Extremities, Joints, Muscles, Spine Skin, Lymph Nodes Neurological Space is available on back page for detailed comments or instructions pertaining to enrollment at child care or preschool. 1

Iowa Child Care Regulations require an admission physical exam report within the previous year. Annually thereafter, a statement of health condition signed by an approved health care provider. The American Academy of Pediatrics has recommendations for frequency of childhood preventative pediatric health care (RE9939, March 2000) www.aap.org 2 Developmental screening procedures were expanded to include autism, developmental surveillance, and psychosocial/behavioral screening July 2009 by the Iowa EPSDT Medicaid program. Toll-free 800-3833826.

The child may participate in developmentally appropriate child care/preschool with the following restrictions:

May use stamp

Signature ____________________________________ Circle the Provider Credential Type: MD DO PA ARNP Address: Telephone:

3

PK phy-health_exam_form.pdf

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