The child care facility must obtain for every child who enrolls in child care programs a signed dated statement of the child’s
current health status which indicates the abilities and/or limitations to participate in a regularly scheduled child care
program.  This report is to be filled out by a licensed physician or other health care professional who has seen the child
in the twelve months.

Name of Facility ________________________________________Type of Facility_____________________________

Child’s Name ____________________________________ Sex ________ Date of birth _________________________

Address _________________________________________________________________________________________

Past Illness-Check those the child has had and give approximate dates:

Chicken Pox _________________   Ruseola ______________________     Rubella ______________________

Rheumatic Fever _____________   Asthma ______________________     Hay Fever ____________________

Diabetes ____________________   Mumps _______________________    Epilepsy ______________________

Whopping Cough _____________   Poliomyelitis __________________    Other ________________________

Comments: _________________________________________________________________________________

Surgery/Accident/Illness/Chronic Heart Problems: ________________________________________________

___________________________________________________________________________________________

Describe any physical or medical condition requiring special attention: ______________________________

___________________________________________________________________________________________

Medication(s) prescribed: _____________________________________________________________________

Allergies: _______________________________ and prescribed routine: ______________________________

If tuberculin test given: Date: _________________________Results : ________________________________

If chest x-ray taken: Date: ____________________________ Results:________________________________

Vision: _____________________________________________ Hearing: _______________________________

Please record immunizations and dates administered on the Colorado Department of Health Certification of Immunization
and attach to this form.

______________________________________________________            ___________________________________
Signature of licensed physician or other health care professional            Date

Please Print:                                                    

_________________________________________
     Name of physician/Health Care Professional            

_________________________________________
                                                 Address                                                                                                             

_________________________________________
                        State                                                  Zip Code                               

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