GENERAL HEALTH APPRAISAL FORM PARENT please complete AND SIGN Child’s Name:_______________________________________________________ Birthdate: _____________________ Allergies: None or Describe___________________________________________________________________________________________
Type of Reaction ____________________________________________________________________________________________________
Diet: Breast Fed Formula _______________________ Age Appropriate
Special Diet ________________________________________________________________________________________________
Sleep: Your health care provider recommends that all infants less than 1 year of age be placed on their back for sleep.
Preventive creams/ointments/sunscreen may be applied as requested in writing by parent unless skin is broken or bleeding. I, ________________________________________ give consent for my child’s care health provider, school child care or camp personnel to discuss my child’s health concerns. My child’s health provider may fax this form (& applicable attachments) to my child’s school, child care or camp personnel. FAX #: _____________________________ DATE: _____________________________ Parent/Guardian Signature___________________________________________________________________ HEALTH CARE PROVIDER: Please Complete After Parent Section Completed Date of Last Health Appraisal: _____________________________ Weight @ Exam: _______________________________________ Physical Exam: Normal Abnormal (Specify any physical abnormalities)_____________________________________________________ Allergies: None or Describe__________________________ Type of Reaction __________________________________________________ 6LJQLÀFDQW+HDOWK&RQFHUQV Severe Allergies Reactive Airway Disease Asthma Seizures Diabetes Hospitalizations
Developmental Delays Behavior Concerns Vision Hearing Dental Nutrition Other ________________________________
Explain above concern (if necessary, include instructions to care providers): ______________________________________________________
Current Medications/Special Diet: None or Describe ______________________________________________________________________
Separate medication authorization form is required for medications given in school, child care or camp
For Fever Reducer or Pain Reliever (for 3 consecutive days without additional medical authorization) PLEASE CHOOSE ONE PRODUCT
Acetaminophen (Tylenol) may be given for pain or fever over 102 degrees every 4 hours as needed
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OR Ibuprofen (Motrin, Advil) may be given for pain or for fever over 102 degrees every 6 hours as needed
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Immunizations: Up-to-Date See attached immunization record Administered today: _____________________________________________ Health Care Provider: Complete if Appropriate **ONLY REQUIRED BY EARLY HEAD START AND HEAD START PROGRAMS PER STATE EPSDT SCHEDULE** ** Height @ Exam _____ ** B/P _____ **Head Circumference (up to 12 months) _______ ** ** HCT/HGB _____ ** Lead Level Not at risk or Level _____ **TB Not at risk or Test Results Normal Abnormal **Screenings Performed: Vision: Normal Abnormal Hearing: Normal Abnormal Dental: Normal Abnormal- Recommended Follow-up________________________________________________________________________________________ Provider Signature 2IÀFH6WDPS
Next Well Visit: Per AAP guidelines* or Age__________
This child is healthy and may participate in all routine activities in school sports, child care or camp SURJUDP$Q\FRQFHUQVRUH[FHSWLRQVDUHLGHQWLÀHGRQWKLVIRUP
_____________________________________________________
Signature of Health Care Provider (certifying form was reviewed) Date: _______________
The Colorado Chapter of the American Academy of Pediatrics (AAP) and Healthy Child Care Colorado have approved this form. 04/07*The AAP recommends that children from 0-12 years have health appraisal visits at: 2, 4, 6, 9, 12, 15, 18 and 24 months, and age 3, 4, 5, 6, 8, 10 and 12 years. Copyright 2007 Colorado Chapter of the American Academy of Pediatrics
SUPREME COURT OF THE STATE OF NEW YORK COUNTY OF 18674-2010 -------------------------------------X BAC HOME LOANS SERVICING, LP FKA NOTICE OF MOTION YASMIN EDWARDS, MORTGAGE ELECTRONIC REGISTRATION SYSTEMS, INC AS NOMINEE FOR COUNTRYWIDE BANK, FSB, ITS PLEASE TAKE NOTICE, that upon the affirmation S. JOHN LENOIR, attorney for the defendant YASMIN EDWARDS, duly sworn to on the 19th day of
CONCURSO DE BAILE ESTUDIANTIL 2009 CONVOCATORIA DE LOS PARTICIPANTES 1. Podrán participar alumnos (as) entre 13 y 18 años de edad quienes deberá integrar grupos de un mínimo de 6 y máximo de 15 participantes; los grupos podrán ser mixtos o de un solo sexo. en dos categorías: 2. Cada grupo deberá representar una coreografía libre con una duración mínima de 3:00 minuto