KDHE Required Health Assessment

MEDICAL RECORD FOR ALL CHILDREN IN CHILD CARE FACILITIES

Parents are to complete the Medical Record and the History of Immunizations for each child in licensed child care facilities. The Medical Record, History of Immunizations, and Child Health Assessment are transferable when the child moves to another licensed child care facility.
Which location will your child attend?*
Child's First Day in Child Care*

MonthDayYear
Date
Child's Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*
M/F
Parent/Guardian 1 Information
Full Name*
First Last Name
Full Address*
Street, City, Zip Code
Home Phone Number
Employer
Work Phone Number
Please enter a valid phone number.
Cell Phone Number*
E mail Address*
example@example.com
Best way to contact*
Parent/Guardian 2 Information
Full Name
First Last Name
Full Address
Street, City, Zip Code
Home Phone Number
Employer
Work Phone Number
Please enter a valid phone number.
Cell Phone Number
E mail Address
example@example.com
Best way to contact
Authorized Pick Up / Emergency Contacts

Persons authorized to pick up the child or to notify in case of emergency (other than the parents):
Full Name*
Address*
Phone Number*
Name*
Address*
Phone Number*
Medical History
Child's Physician*
Phone Number*
Child's Dentist*
Phone Number*
Hospital Preference (for emergencies)*
Has your physician approved the use of any non-prescription medications for your child such as acetaminophen, cough syrup, or ointments that can be given by the child care provider?*

YesNo
Yes, as follows:*
Any known allergies or medical conditions of child:*
List N/A if no known allergies
Any major changes at home that might affect your child in care:*
List N/A if none at this time
Please provide additional information or special instructions that will help the person caring for your child:*
List N/A if none at this time
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date

	1st dose	2nd dose	3rd dose	4th dose	5th dose	6th dose
Diphtheria, Tetanus, Pertussis (DTaP)
Poliomyelitis (IPV/OPV)
Measles, Mumps, Rubella (MMR)
Hepatitis B (HepB)
Varicella (VAR)
Hemophilus Influenzae Type B (Hib)
Pneumococcal Conjugate (PCV)
Hepatitis A (HepA)
Rotavirus **Recommended <8 mo of age; not required
Influenza(Flu) ** Recommended annually >6 mo of age; not required

MEDICAL RECORD FOR ALL CHILDREN IN CHILD CARE FACILITIES

Parent/Guardian 1 Information

Parent/Guardian 2 Information

Authorized Pick Up / Emergency Contacts

Medical History

History of Immunizations

Section 1

Section 2

Child Health Assessment