Does the child have any known allergies or food restrictions? Does this child have any limiting physical difficulties? Has this child received any psychological diagnoses (e.g., ADD/ADHD, Autism, ODD, etc.)? Has this child ever been hospitalized for a serious injury (e.g., broken bones, head trauma, bleeding)? Has this child ever been hospitalized for a significant illness (e.g., pneumonia, asthma, etc)? Has this child ever been hospitalized for behavioral or emotional problems? Medical Diagnoses Date of Current Medications Label Comments Diagnosis (if any) Diagnosis 1 Diagnosis 2 Diagnosis 3 Allergies or Food Restrictions Date of Current Medications Label Comments Diagnosis (if any) Restriction 1 Restriction 2 Restriction 3 Physical Limitations Date of Current Medications Label Comments Diagnosis (if any) Difficulty 1 Difficulty 2 Difficulty 3 Psychological Diagnosis Date of Current Medications Label Comments Diagnosis (if any) Diagnosis 1
Does the child have any known allergies or food restrictions? Does this child have any limiting physical difficulties? Has this child received any psychological diagnoses (e.g., ADD/ADHD, Autism, ODD, etc.)? Has this child ever been hospitalized for a serious injury (e.g., broken bones, head trauma, bleeding)? Has this child ever been hospitalized for a significant illness (e.g., pneumonia, asthma, etc)? Has this child ever been hospitalized for behavioral or emotional problems? Medical Diagnoses Label Date of Diagnosis Current Medications (if any) Comments Diagnosis 1 Diagnosis 2 Diagnosis 3 Allergies or Food Restrictions Label Date of Diagnosis Current Medications (if any) Comments Restriction 1 Restriction 2 Restriction 3 Physical Limitations Label Date of Diagnosis Current Medications (if any) Comments Difficulty 1 Difficulty 2 Difficulty 3 Psychological Diagnosis Label Date of Diagnosis Current Medications (if any) Comments Diagnosis 1