MEDICAL EXAMINATION

Employee Name: ______________________________ Date: ______________________

Dear Doctor:
The above named individual has applied to work in our day care centre caring for groups of children from
infancy up to school age. Please fill out the information below to the best of your knowledge. Thank you for
your cooperation in this matter. Kids & Company

To the best of my knowledge, the above named person is in good health and free of communicable disease.

Illness or Disabilities:
______________________________________________________________________________
______________________________________________________________________________

Medications: ______________________________________________________________________________
___________________________________________________________________________

2 STEP TB test: (2 Step is only once in life-proof is required on file)

Date #1 ______________________________ Result:______________________________
Date #2 ______________________________ Result: _____________________________
If positive, date and result of x-ray:
______________________________________________________________________________

1 STEP TB test: (1 Step is required upon hire even with proof of a 2 Step)
Date ______________________________ Result: _____________________________
If positive, date and result of x-ray:
______________________________________________________________________________

Date of last Tetanus, Diphtheria and Polio booster: (every 10 years) _______________________

Date of last M.M.R. immunization:___________________________________________

(One dose after 1st birthday. Not required if born prior to 1970 or if has lab-documented immunity to all three infections).

Signature of Physician: ____________________________________Date: __________________

Address: ______________________________________________________________________

Phone #: _____________________________________