Child Medical Record

Version 2026.1 · Effective August 23, 2026

Child information

• Full name: _____________________________________________________
• Preferred name: ________________________________________________
• Date of birth: ____________________
• Home address: _________________________________________________

Parent/guardian information

Healthcare information

• Primary healthcare provider and phone: ___________________________
• Dentist and phone: _____________________________________________
• Preferred hospital or emergency facility: ________________________
• Insurance provider and member number: ___________________________

Health conditions and care needs

Please list any condition, diagnosis, developmental consideration, health plan, or care need that may affect the child’s care. Attach an individual care plan or healthcare-provider instructions when required.

__________________________________________________________________

__________________________________________________________________

☐ No known conditions or special care needs at this time.

Allergies and reactions

☐ No known allergies at this time.

Medication and topical products

☐ No medication or topical product is required during care.

☐ Medication or topical product information is attached. Separate written authorization and healthcare-provider instructions may be required.

Details: ________________________________________________________

Nutrition and dietary restrictions

☐ No known dietary restrictions.

☐ Allergy-related dietary restriction.

☐ Medical or religious dietary restriction.

☐ Other: ________________________________________________________

Instructions and required foods/substitutions: _____________________

__________________________________________________________________

Immunization or exemption

☐ Current immunization documentation attached.

☐ Applicable exemption documentation attached.

☐ Documentation is pending and will be provided by: _______________

Attachments

☐ Physician health appraisal or evaluation

☐ Immunization certificate or exemption

☐ Allergy, asthma, seizure, or other individual health plan

☐ Medication authorization and healthcare-provider instructions

☐ Emergency medical authorization

Parent certification and updates

I certify that the information provided is accurate to the best of my knowledge. I will notify Teida’s Tots promptly when any information changes and will provide updated plans, authorizations, and medical documentation when required.

• Parent/guardian signature: ______________________________________
• Printed name: _________________________________________________
• Date: ____________________

Annual review