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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 COMPL....

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232