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"Revealing the Heart of Christ to Everybody, Everywhere and Every Time"
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Teacher's Edition
Child Medical Record Form
Child Medical Record Form
Child’s Name:
Birthdate:
Father/Guardian Name:
Phone:
Mother/Guardian Name:
Phone:
Primary Physician:
Phone:
Address:
Is your child currently under the supervision of a physician?
Yes
No
If Yes Explain:
Please answer ALL of the questions below.
Yes or No
Does your child have any history of vision impairment?
Yes
No
Does your child wear corrective lenses?
Yes
No
Does your child have a hearing impairment?
Yes
No
Does your child wear a hearing- aid?
Yes
No
Does your child have a speech impediment?
Yes
No
Has your child ever been tested for intellectual disability or developmental delay?
Yes
No
Does your child have an IEP?
Yes
No
Does your child have an existing illness?
Yes
No
Does your child currently take medication?
Yes
No
Does your child have allergies?
Yes
No
Has your child been diagnosed with an emotional disorder?
Yes
No
Has your child been diagnosed with a behavioral disorder?
Yes
No
Is your child participating in a behavioral intervention plan?
Yes
No
Is your child participating in a reinforcement plan?
Yes
No
Please provide any special instructions regarding any medical questions
Please provide any additional information regarding this form.
General Comments:
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