ACULUMULATION FORM NEW YORK CITY DEPARTMENT OF HEALTH AND MENTAL HYGIENE BUREAU OF DAY CARE DAY CARE CUMULATIVE HEALTH RECORDCENTERNAME: ADDRESS: BORO: Date of Admission MM slash DD slash YYYY Name Last - First - MiddleSex F M DATE OF BIRTH MM slash DD slash YYYY Address No - Street - City/Boro - State - ZipMother's Name Last - First Father's Name Last - First TELEPHONE NO HOMETELEPHONE NO WORKFOSTER PARENTFOSTER AGENCY ADDRESS TELEPHONELANGUAGE SPOKEN IN HOME PERSON/S TO CONTACT IN CASE OF EMERGENCY (Other Than Parent)NAME RELATIONSHIP TO CHILD ADDRESS TELEPHONE NO HOME TELEPHONE NO WORK NAME OF MEDICAL PROVIDER, CLINIC OR HOSPITALNAME CONTACT PERSON PATIENT NO ADDRESS TELEPHONE NO SIGNIFICANT FAMILY HISTORY Sickle Cell Heart Disease Hearing Diabetes Hypertension Convulsive Disorder Tuberculosis Allergies Vision None IS CHILD ALLERGIC TO ANY Medications Specify None Specify Foods Specify Insect Bites Specify HOSPITALIZATIONS AND ILLNESSESHas child ever been hospitalized or operated on? Yes No EXPLAINHas child ever had a serious accident (broken bone, head injury, fall, burns, poisoning)? Yes No EXPLAINHas child ever had a serious illness? Yes No EXPLAINSPECIAL HEALTH CONDITIONS(Long term or chronic)1 AGE IT BEGAN TREATMENT/MEDICATIONS 2 AGE IT BEGAN TREATMENT/MEDICATIONS 3 AGE IT BEGAN TREATMENT/MEDICATIONS 4 AGE IT BEGAN TREATMENT/MEDICATIONS 5 AGE IT BEGAN TREATMENT/MEDICATIONS Who fills out this form I hereby certify that information provided herein is complete and accurateCONSENT FOR EMERGENCY MEDICAL TREATMENT (REQUIRED FOR ADMISSION TO DAY CARE) I do hereby give authority to the day care program staff to obtain necessary emergency medical treatment for my child,with the understanding that the family will be notified as soon as possible. SignatureDate MM slash DD slash YYYY RELATIONSHIP Notary Public or Commissioner of Deeds (OPTIONAL) County of
