Medical Record | Daydreams Childcare Center

Daydreams Childcare Center

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Medical Record

Alternate printable Medical Record Form you can sign and return.

Child's Info

Child's Name

Date of Birth

Parent Name

Email Address

Home Phone

Doctor's Name

Doctor's Phone

Medical Info

Has the Child had

Measles Chickenpox Whooping Cough Other

Other

Any History of

Skin Conditions Ear Infection Asthma Bronchitis Pneumonia Convulsions

Any special treatment necessary?

Yes No

If yes, details

Immunizations (Give Dates)

Polio/Whooping Cough (2 months)

Polio/Whooping Cough (4 months)

Polio/Whooping Cough (6 months)

Polio/Whooping Cough (12 months)

Polio/Whooping Cough (18 months)

Other (chicken pox)

Certification

I hereby certify that is is not free from communicable diseases.

Your Name

Today's Date

Contact Us • 28 & 34 Bluewater Rd, Bedford, NS • (902) 835-5437 •