Child Health Report

"*" indicates required fields

Use of form: Use of this form is voluntary; however, completion of this form meets the requirements of DCF 202.08(4), DCF 250.04(6)(a)4. and DCF 251.04(6)(a)8. Failure to comply with these rules may result in issuance of a noncompliance statement. Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04(1)(m), Wisconsin Statutes].
Instructions: Each child under 2 years of age shall have an initial health examination not more than 6 months prior to nor later than 3 months after being admitted to the center and a follow-up health examination at least once every 6 months thereafter. Each child 2 years of age but who is not 5 years of age or older shall have an initial health examination not more than one year prior to nor later than 3 months after being admitted to a center and a follow-up health examination at least once every 2 years thereafter. The parent / guardian shall give this form to the physician, physician assistant, or other EPSDT provider to be completed, signed, and dated. The licensee / operator shall obtain a copy for the child’s record. Note: Children are also required to have on file at the child care center documentation of immunizations; it may be helpful if the parent / guardian includes a copy of the child’s immunization record when submitting this form to the child care center.

PARENT OR GUARDIAN

This section should be completed by the parent or guardian

Child’s Name*

First Last

Child’s Birthdate*

Child’s Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent or Guardian Name*

First Last

Parent or Guardian Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

HEALTH PROFESSIONAL

This section should be completed by the health professional

Instructions for feeding and care of child with special health concerns – Specify: (attach information as necessary).*

Does the child have a milk allergy? If “Yes,” identify the recommended milk substitute.*

Yes

Recommended milk substitute.

Does this child have any food or non-food allergies? If “Yes,” specify and include the treatment plan to be implemented in the event of an allergic reaction.*

Yes

Specify and include the treatment plan to be implemented in the event of an allergic reaction.

Date of child’s most recent blood lead test:*

Note: Children on Medicaid are required to be tested at around ages 12 months and 24 months or once between the ages of 3 and 5 years if no previous test is documented. Lead testing is optional for children who are not on Medicaid.

Immunization(s) not to be administered to child due to medical reason(s) – Specify.*

AUTHORIZATION

I certify that I have examined the above child on this date and that he / she is able to participate in child care activities.

Name – MD, PA, or other EPSDT Provider*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

SIGNATURE – MD, PA, or other EPSDT Provider*

Date of Examination*