MISSOURI DEPARTMENT OF SOCIAL SERVICES

CHILDREN'S DIVISION

RESIDENTIAL PROGRAM UNIT

CHILD’S MEDICAL REPORT

NAME:
DATE OF BIRTH:
MEDICAID NUMBER:

RACE:	SEX:	HEIGHT:	WEIGHT:
TEMP:	PULSE:	RESP.:	BP:

HISTORY OF ILLNESS: (ENTER THE YEAR IN WHICH CHILD HAD THE FOLLOWING:

CHICKEN POX	RUBELLA	MEASLES
MUMPS	SCARLET FEVER	STREP THROAT
RHEUMATIC FEVER	MENINGITIS	DIABETES
HEPATITIS (JAUNDICE)	PNEUMONIA	ASTHMA
TUBERCULOSIS	SEIZURE DISORDER	POLIOMYELITIS

DATE AND TYPE OF TB TEST GIVEN:
RESULTS OF TB TESTING:

KNOWN ALLERGIES:

MEDICATIONS PRESCRIBED AND PURPOSE:

FINDINGS OF THE PHYSICAL EXAMINATION:
FINDINGS OF A NEUROLOGICAL EXAMINATION:
LABORATORY OR TEST RESULTS:
ARE ANY ADDITIONAL TESTS NEEDED?

THIS CHILD WILL BE ENGAGING IN A FULL RANGE OF PHYSICAL ACTIVITY AND RECREATION. ARE THERE ANY SIGNIFICANT PHYSICAL DISABILITIES WHICH COULD LIMIT THIS CHILD’S ENGAGEMENT IN STRENUOUS PHYSICAL ACTIVITIES? IF YES, PLEASE SPECIFY:

TREATMENT RECOMMENDED:

Signature of Physician or Registered Nurse under the Supervision of a Physician	Date	Physician’s or Nurse’s Name (Please Print
Name of Clinic, Group Practice, Other	If Nurse is Supervised by a Physician, indicate Physician’s Name
Address (Street, City, State and Zip Code)	Telephone Number

THIS REPORT IS TO BE KEPT ON FILE AT THE RESIDENTIAL CHILD CARE OR CHILD PLACING AGENCY

MO 886-3332 REV 03-12	RPU-10D

HISTORY OF IMMUNIZATION REQUIRED BY MISSOURI STATE LAW

1ST	2ND	3RD	4TH	5TH
INITIAL SERIES	MONTH	DAY	YEAR	MONTH	DAY	YEAR	MONTH	DAY	YEAR	MONTH	DAY	YEAR	MONTH	DAY	YEAR
DPT
T. d.
POLIO ORAL
MEASLES
MUMPS
RUBELLA
MMR
HIB
HBV
TB TEST

MO 886-3332 REV 03-12	RPU-10D