Child Health & Medical Record

Everything care staff need to know to keep your child safe and well. Update whenever anything changes.

Wylari

Child's full name

Date of birth

Date completed

Physician

Phone

Dentist (if any)

Phone

Insurance provider

Policy #

Date of last physical

Allergies

Allergen (food, medication, insect, environmental)	Reaction	What to do

No known allergies Epinephrine auto-injector on site? Yes No

Current Medications

Medication	Dose	When given	Notes

Anything given at daycare needs its own signed medication authorization and must arrive in the original container.

Health History & Conditions

Asthma Seizures Diabetes Heart condition Hearing / vision concern Feeding / swallowing concern Other

Details for anything checked (triggers, warning signs, what helps)

Anything else that helps us care for your child (dietary needs, mobility, sensory, developmental notes)

Immunizations

Current immunization record attached Exemption on file (form per state rules)

Most states require the official immunization record or exemption form in the child's file — this page doesn't replace it.

Signature

Parent / guardian signature

Date

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