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Medical-Physical Statements for Colorado Child Care Employees $39

Scheduling Your Appointment

Complete your medical history survey. It's designed specifically for childcare employees. A Nurse or Physician will review your answers to determine if we need more information from you. 

Click Pay and Schedule Your Appointment* 

*You are making a precautionary phone call appointment in the event we need to call you to discuss your medical condition.

Doctor asking a patient to sign a typed form on a clipboard acknowledging test results, an

Please, do not fill out this form for another person!

Medical History Survey

My job responsibilities may include the following. Check all that apply.
Do you have any medical, mental, physical, or communicable disease conditions that could interfere with your ability to safely work with children?
Do you have any of the following medical conditions? Check all that apply
Do you have any of the following communicable disease conditions? Check all that apply
Do you experience any of the follow physical limitations? Check all that apply
Do you have enough strength to pick up the children you work with and carry them a short distance?
Are you currently under any medically prescribed work restrictions?
Currently, has your employer made any modifications to your job duties because of your medical condition?
Did you receive all your childhood immunizations?
Do you agree to immediately contact your doctor for any changes to your physical, mental, or emotional health that could interfere with you safely working with children?
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