Susanna Nursery School - HEALTH FORM


Health Check-up Form

Susanna Wesley Nursery School

601 Main Street

Mt. Vernon, IN   47620

Fax # (812)838-2643


Child’s Name_________________________________________________________ Date____/____/________


1.  This child was examined and is in good health.  He/She is free from physical limitations and may participate in all activities without restrictions.           YES         NO (Please explain)__________________________________________



2.  His/Her immunizations are current.      YES       NO (If no, which one(s) are not up to date for his/her age?       ___________________________________________________________________________________________________________


3. Has he/she been exposed to any communicable diseases at this time?       YES       NO


4. Additional remarks ____________________________________________________________


Signature of Physician___________________________________


Printed name of Physician____________________________________  Phone(        )______________________