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HEALTH CARE SUMMARY <br />(CO be completed by health care source) <br />Date of Enrollment <br />NAME OF CHILD Birth Cate <br />ADDRESS Telephone <br />PARENT/S OR GUARDIAN, <br />Date of last physical examination <br />How long have you been seeing this child? <br />Does this child have any allergies (including allergies to meds?) <br />Is a modified diet necessary?. <br />Is any condition present that < esult in an emergency? <br />Vhat is the status of the child's . . Vision <br />Hearing, <br />Speach_ <br />Flaase list below the important health problems. <br />Indicate if you or someone else is following the child for the problem, and <br />check which problems require special attention at the center. <br />Followed Followed by other Requires Special <br />Taportant Health Promblems bv VOU Med Source(Name) AtttDtlgn <br />Other information helpful to the group day care center <br />Source of health care Associates or clinic <br />Seta Address