MEDICAL HISTORY AND IMMUNIZATION
Dear Physician,  

The child by the name of______________________________ is enrolled in a Group Child Care Facility, which is registered by the Mass.

 Office of Child Care Services. The OCCS regulations require the Medical History form to be completed and signed by the child’s physician 

or source of health care and be returned to the Center within ONE MONTH of enrollment. A prompt response is appreciated.

Name of Child:

Name of Parents:

Address:

 

City, State, Zip:

Address:

Phone #

Phone #

    IMMUNIZATION:                           DATES:                               IMMUNIZATION:                            DATES:

Diphtheria

 

Measles

 

Pertussis

 

Mumps

 

Tetanus

 

Rubella

 

Poliomyelitis

 

HIB Vac

 

Date of last exam of child:___________________________________________________________________

What is your opinion concerning this child’s general health and appearance?____________________________

________________________________________________________________________________________

Has this child been tested for lead poisoning?          YES___________    NO_____________

(Mass OCCS requires that ALL children be tested prior to enrollment)

Date Tested___________________________   Results______________________________________

Does this child have any handicaps or chronic medical problems (allergies, limited vision, loss of hearing, etc) 

which would require special consideration or care by the daycare provider? If so please detail.

 

______________________________________________________________________________________

Physician’s Signature:_______________________________________  Date:______________________

Additional Comments:____________________________________________________________________________

________________________________________________________________________________