PHYSICAL EXAMINATION FORM
To be completed and approved by the child´s diabetes nurse educator, endocrinologist, or primary care provider/physician. Please attach additional pages as needed.
Dear Diabetes Team:
Your cooperation in supplying the following information about an applicant for Rainbow River Child Development Center is greatly appreciated. The child will not be accepted without your approval on this form.
To Parent/Guardian: Please complete boxed information BEFORE submitting to Physician.
Name of applicant___________________________ Gender (circle one) M F
Date of Birth _______/_________ Address:____________________________________
Date of most recent exam: _____________________
I have read the Diabetes Management Plan, attached to this form, and certify that it provides an easy to understand, complete regime of care for this child´s safety at Rainbow River Child Development Center, I recognize that the child will be active at this facility and represent that this plan accounts for applicable varying activity levels.
Have any complications of health or disabilities been detected? Yes/No (circle one)
If yes, please specify:
Is the child emotionally and physically mature or responsible enough to independently manage his/her health concerns? Yes______; No_____.
Do you have any specific concerns regarding the management of this child´s health or health at school not fully described in the Medical Management Plan? Yes____, No____.
If yes, please explain:______________________________________________________
Do you recommend any limitation on child´s activity while at the day care facility beyond those described in the Medical Management Plan? Yes _______ No ______ If yes, please describe:_______________________________________________________
Do you have any other information that is relevant to the care of this child? Yes __ No __
If yes, please describe: _____________________________________________________
I certify that the information above is correct to the best of my knowledge and agree to answer questions and provide management guidance to Rainbow River Child Development Center as requested by the facility at the sole cost and expense of the parent/legal guardian of the child.
Primary Care Physician/Endocrinologist´s Name (typed or printed)
Primary Care Physician/Endocrinologist´s Signature:
Parents/Guardians name (typed or printed)
Legal Guardian: ____________________________