Child Daycare Entry Physical Exam
Child Information
Full Name
Date of Birth
Sex
Male
Female
Other
Parent/Guardian Name
Daycare Name
Medical History
Allergies
Current Medications
Chronic Conditions
Past Illnesses/Surgeries
Immunizations
Up to Date?
Yes
No
If not, specify
Physical Exam
Height (cm)
Weight (kg)
Vision
Hearing
TB Screening
Normal
Abnormal
General Exam Findings
Restrictions/Recommendations
Physician Information
Provider Name
Date of Exam
Signature