Health Check-up Form
Susanna Wesley Nursery School
601 Main Street
Mt. Vernon, IN 47620
Fax # (812)838-2643
Child’s Name_________________________________________________________ Date____/____/________
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
4. Additional remarks ____________________________________________________________
Signature of Physician___________________________________
Printed name of Physician____________________________________ Phone( )______________________
