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Get Form No 604 554 2

PROGRAM CHILD IS ENROLLED IN Head Start - State Preschool Head Start Center Base Early Head Start Home Base FCC Confidential Medical Record Part II Physical Exam and Screening Tests LAST NAME FIRST NAME MIDDLE INITIAL OF CHILD SEX DATE OF BIRTH M NAME OF PARENT OR GUARDIAN F DELEGATE AGENCY NAME/SITE TO BE COMPLETED BY HEALTH CARE PROVIDER PHYSICAL EXAMINATION ADMINISTERED BY TYPE OR PRINT NAME TYPE OF PRACTICE SIGNATURE TELEPHONE NUMBER DATE OF EXAM ADDRESS EXAMINATION RESULTS HEIGHT inches EXAM HEAD lbs/oz Normal Abnormal Blood Pressure age 3 Skin Head Neck Lymph Nodes Eyes Ears Nose BMI for age Mouth/Teeth/ Oral Health Throat Chest Lungs Heart Back Abdomen Vision Acuity Age 3 Right Left Both Date of Test 20/ Hearing Age 3 Laboratory - Tests Results HCT gms DATE DATE GIVEN RESULTS mcg/dl DATE OF FOLLOW-UP APPOINTMENT dB DATE READ mm Significant DATE OF CHEST X-RAY RX DATE Treatment / Restrictions / Recommendations for School DATE OR AGE NEXT PHYSICAL EXAM DUE SIGNATURE OF STAFF COMPLETING 1ST REVIEW POSITION HEAD START FOLLOW-UP REFERRED FOR FOLLOW-UP TO Nutrition Disabilities MH Other INITIALS/DATE FORM RECEIVED FORM NO. 604-555 06/26/2012 Non Diagnosis / Abnormal Findings PPD - TB Screening LEAD TREATMENT Left Ear 1000 Hz Type of Test HGB Right Ear Frequency Genitalia Neurologic Extremities Motor Ability Psychological Speech Hearing Birth to 3 Vision Birth to 3 CIRCUMFERENCE FCP Education. PROGRAM CHILD IS ENROLLED IN Head Start - State Preschool Head Start Center Base Early Head Start Home Base FCC Confidential Medical Record Part II Physical Exam and Screening Tests LAST NAME FIRST NAME MIDDLE INITIAL OF CHILD SEX DATE OF BIRTH M NAME OF PARENT OR GUARDIAN F DELEGATE AGENCY NAME/SITE TO BE COMPLETED BY HEALTH CARE PROVIDER PHYSICAL EXAMINATION ADMINISTERED BY TYPE OR PRINT NAME TYPE OF PRACTICE SIGNATURE TELEPHONE NUMBER DATE OF EXAM ADDRESS EXAMINATION RESULTS HEIGHT inches EXAM HEAD lbs/oz Normal Abnormal Blood Pressure age 3 Skin Head Neck Lymph Nodes Eyes Ears Nose BMI for age Mouth/Teeth/ Oral Health Throat Chest Lungs Heart Back Abdomen Vision Acuity Age 3 Right Left Both Date of Test 20/ Hearing Age 3 Laboratory - Tests Results HCT gms DATE DATE GIVEN RESULTS mcg/dl DATE OF FOLLOW-UP APPOINTMENT dB DATE READ mm Significant DATE OF CHEST X-RAY RX DATE Treatment / Restrictions / Recommendations for School DATE OR AGE NEXT PHYSICAL EXAM DUE SIGNATURE OF STAFF COMPLETING 1ST REVIEW POSITION HEAD START FOLLOW-UP REFERRED FOR FOLLOW-UP TO Nutrition Disabilities MH Other INITIALS/DATE FORM RECEIVED FORM NO. 604-555 06/26/2012 Non Diagnosis / Abnormal Findings PPD - TB Screening LEAD TREATMENT Left Ear 1000 Hz Type of Test HGB Right Ear Frequency Genitalia Neurologic Extremities Motor Ability Psychological Speech Hearing Birth to 3 Vision Birth to 3 CIRCUMFERENCE FCP Education.

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