Preston Academy Children's Medical Report - Preston Children's Academy

Name of Child

First Middle Last

Child's Date of Birth

Name of Parent or Guardian

First Middle Last

Address of Parent/Guardian

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Medical History (To be completed by parent)

Is your child allergic to anything?

yes
no

If yes, explain:

Is your child currently under a doctor's care?

yes
no

If yes, explain:

Is your child on any continuous medication?

yes
no

If yes, explain:

Any previous hospitalizations or operations?

yes
no

If yes, explain:

Any history of significant previous diseases, recurrent illness, or disabilities? Check any of the following:

diabetes
convulsions
heart trouble
physical disabilities
mental disabilites
Other

If yes, please explain:

Required Signature

Step 1: Check the box below*

By checking this box and typing my name below, I am electronically signing my application

Step 2: Type in your name*

First Middle Last Suffix

Please upload a copy of your child's immunization record here or bring us a hard copy:

Drop files here or

This examination must be completed and signed by a licensed physician, his/her authorized agent currently approved by the N.C. Board of Medical Examiners (or a comparable board from bordering states), a certified nurse practitioner, or a public health nurse meeting DEHNR standards for EPSDT program.