Susanna Nursery School - HEALTH FORM

SWNS - HEALTH FORM

Health Check-up Form

Susanna Wesley Nursery School

601 Main Street

Mt. Vernon, IN   47620

Fax # (812)838-2643

 

Child’s Name_______________________________________________    Date of Exam:____/____/________

 

1.  This child was examined and is in good health.  He/She is free from physical limitations and may participate in all activities without restrictions.           YES         NO (Please explain)_____________________________________________________________________________________________________________________________________

 

2.  His/Her immunizations are current.      YES       NO (If no, which one(s) are not up to date for his/her age?   ___________________________________________________________________________________________

___________________________________________________________________________________________

 

3. Has he/she been exposed to any communicable diseases at this time?       YES       NO

            If YES, which one? _____________________________________________________________________

 

4. Additional remarks _________________________________________________________________________

 

Signature of Physician___________________________________

 

Printed name of Physician________________________________  Phone__________________________