Tender Love and Care (tlc) Medical Form & Questionnaire



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Child’s Passport Photo



Tender Love and Care (TLC)

Medical Form & Questionnaire

(All Medical Records are kept Confidential)





Name (First/Middle/Last):

     

Gender:

Male Female

Date of Birth:

     

Place of Birth:

     

Father’s Name:

     

Mother’s Maiden Name:

     

Home Address:

     

Telephone Number:

     




To be completed by your Child’s Pediatrician or Family Doctor

Family History:




Do any of your family members have?




Yes

No




Yes

No

Hypertension





Thalassemia





Migraine





Anemia





Nervous Disorder





Allergies





Epilepsy





Cancer





Heart Disorder





Diabetes





Cholesterol





Others





Remarks:      




Child’s Past Medical History:
















Has your child had any of the following conditions or diseases?




Yes

No




Yes

No

Chicken Pox





Poliomyelitis





Measles





Whooping Cough





German Measles





Diphtheria





Scarlet Fever





Hepatitis





Mumps





Typhoid Fever





Tuberculosis





Cholera





Others (specify):      

Child’s blood group:

     













Was the child ever admitted to a hospital?

Yes

No










If yes, please give reason:

     

Operation if any:

     

Date and result of last PPD (Tuberculin test):

     



Tender Love and Care (TLC)

Medical Form & Questionnaire




Child’s Present History:




Yes

No




Yes

No

Eczema





Thalassemia





Epilepsy





Sickle Cell Anemia





Migraine





Allergy





Hearing problem





Hay fever





Vision problem





Bleeding tendency





Asthma





Diabetes





High blood pressure





Cholesterol





Rheumatic Fever





Kidney Disease








Is the child taking any medication regularly? If yes, please specify:

     





Are there any instructions given by your private physician that you need to mention or inform us about?

     





Height:       cm

Weight:       Kg

H.B:       Beats / minute

BP:       mm/hg




Vision:

Right:       /20

Corrected by eyeglasses




Left:       /20

Corrected by eyeglasses

Hearing:

Normal

Fair

Weak

Speaking:

Normal

Fair

Weak




IMMUNIZATIONS ( Please enter Dates as applicable)




Date




Date

B.C.G.







Diphtheria, Tetanus, Pertussis (Triple) 1

     

& Polio

     

Diphtheria, Tetanus, Pertussis (Triple) 2

     

& Polio

     

Diphtheria, Tetanus, Pertussis (Triple) 3

     

& Polio

     

Diphtheria, Tetanus, Pertussis (Triple) Booster

     

& Polio

     

Measles, Mumps, and German Measles (M.M.R.)

     







H.I.B. 1.

     

H.I.B. 1.

     

H.I.B. 2.

     

H.I.B. 2.

     

H.I.B. 3.

     

H.I.B. 3.

     




Any Other Immunizations?

     



Tender Love and Care (TLC)

Medical Form & Questionnaire


(PLEASE SEND A COPY OF THE ORIGINAL IMMUNIZATION CARD INCLUDING ALL THE VACCINES GIVEN TO THE CHILD BY HIS/HER PEDIATRICIAN.)


Physical Exam

Normal

Abnormal

Remarks

General Appearance

     

     

     

Skin

     

     

     

Mouth - Teeth

     

     

     

Head

     

     

     

Eyes

     

     

     

Ears

     

     

     

Nose & Sinuses

     

     

     

Throat & Thyroid

     

     

     

Skeletal System

     

     

     

Respiratory System

     

     

     

Heart & Blood vessels

     

     

     

Lymphatic System

     

     

     

Neurological System

     

     

     

G I System

     

     

     

Urinary System

     

     

     

Reproductive System

     

     

     

Others

     

     

     




Physician’s Name:

     

Signature:      

Date:      













Physician’s Mobile No:

     

Clinic No:      
















Clinic/Hospital:

     













Name:

     





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