Common use of TO BE COMPLETED BY HEALTH CARE PROVIDER Clause in Contracts

TO BE COMPLETED BY HEALTH CARE PROVIDER. Date of Physical Examination: Results of physical examination normal? Yes No Abnormalities Noted: Weight (must be taken within 30 days for WIC) Height (must be taken within 30 days for WIC) Head Circumference (if <2 Years) Blood Pressure (if >3 Years) IMMUNIZATIONS Immunization Record Attached Date Next Immunization Due: Chronic Medical Conditions/Related Surgeries • List medical conditions/ongoing surgical concerns: None Special Care Plan Attached Comments Medications/Treatments • List medications/treatments: None Special Care Plan Attached Comments Limitations to Physical Activity • List limitations/special considerations: None Special Care Plan Attached Comments Special Equipment Needs • List items necessary for daily activities None Special Care Plan Attached Comments Allergies/Sensitivities • List allergies: None Special Care Plan Attached Comments Special Diet/Vitamin & Mineral Supplements • List dietary specifications: None Special Care Plan Attached Comments Behavioral Issues/Mental Health Diagnosis • List behavioral/mental health issues/concerns: None Special Care Plan Attached Comments Emergency Plans • List emergency plan that might be needed and the sign/symptoms to watch for: None Special Care Plan Attached Comments Hgb/Hct Hearing Lead: Capillary Venous Vision TB (mm of Induration) Dental Other: Developmental Other: Scoliosis Name of Health Care Provider (Print) Health Care Provider Stamp: Signature/Date CH-14 OCT 17 Distribution: Original-Child Care Provider Copy-Parent/Guardian Copy-Health Care Provider Please have the parent/guardian complete the top section and sign the consent for the child care provider/school nurse to discuss any information on this form with the health care provider. The WIC box needs to be checked only if this form is being sent to the WIC office. WIC is a supplemental nutrition program for Women, Infants and Children that provides nutritious foods, nutrition counseling, health care referrals and breast feeding support to income eligible families. For more information about WIC in your area call 0-000-000-0000.

TO BE COMPLETED BY HEALTH CARE PROVIDER. Date of Physical Examination: Results of physical examination normal? Yes No Abnormalities Noted: Weight (must be taken within 30 days for WIC) Height (must be taken within 30 days for WIC) Head Circumference (if <2 Years) Blood Pressure (if >3 Years) IMMUNIZATIONS Immunization Record Attached Date Next Immunization Due: Chronic Medical Conditions/Related Surgeries • List medical conditions/ongoing surgical concerns: None Special Care Plan Attached Comments Medications/Treatments • List medications/treatments: None Special Care Plan Attached Comments Limitations to Physical Activity • List limitations/special considerations: None Special Care Plan Attached Comments Special Equipment Needs • List items necessary for daily activities None Special Care Plan Attached Comments Allergies/Sensitivities • List allergies: None Special Care Plan Attached Comments Special Diet/Vitamin & Mineral Supplements • List dietary specifications: None Special Care Plan Attached Comments Behavioral Issues/Mental Health Diagnosis • List behavioral/mental health issues/concerns: None Special Care Plan Attached Comments Emergency Plans • List emergency plan that might be needed and the sign/symptoms to watch for: None Special Care Plan Attached Comments Hgb/Hct Hearing Lead: Capillary Venous Vision TB (mm of Induration) Dental Other: Developmental Other: Scoliosis Name of Health Care Provider (Print) Health Care Provider Stamp: Signature/Date CH-14 OCT 17 JUL 12 Distribution: Original-Child Care Provider Copy-Parent/Guardian Copy-Health Care Provider Please have the parent/guardian complete the top section and sign the consent for the child care provider/school nurse to discuss any information on this form with the health care provider. The WIC box needs to be checked only if this form is being sent to the WIC office. WIC is a supplemental nutrition program for Women, Infants and Children that provides nutritious foods, nutrition counseling, health care referrals and breast feeding support to income eligible families. For more information about WIC in your area call 0-000-000-0000.