District of Columbia Child Health Certificate FormDistrict of Columbia Child Health Certificate Form
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CONFIDENTIAL FORM-SIDE ONE

PLEASE REVIEW INSTRUCTIONS ON SIDE TWO

DISTRICT OF COLUMBIA CHILD HEALTH CERTIFICATE

Part 1: Child’s Personal Information

Child’s Last Name

Parent or Guardian Name

Parent/Guardian: Please complete Part 1 clearly and completely & sign Part 6 below.

Child’s First & Middle Name

Date of Birth

Telephone1: † Home † Cell

Gender:

Race/Ethnicity:

†M †F

† Hispanic

† White Non Hispanic

† Asian or Pacific Islander

† Black Non Hispanic

† Other______________

Home Address:

Ward

† Work

Emergency Contact:

City/State (if other than D.C.)

Telephone2: † Home † Cell

Zipcode:

† Work

School or child care facility:

† Medicaid

† Private Insurance

† None

Primary Care Provider (PCP):

† Other ________________________________

Part 2: Child’s Health History, Examination & Recommendations.

DATE OF HEALTH EXAM:
HEALTH CONCERNS:
Dental-Oral Health
† None
Asthma
† None
Development
† None
Behavioral/Emotional
† None
Learning/Attention
† None

WT

† YES
† YES
†