EARLY HEAD START/HEAD START MEDICAL FOLLOW‑UP 
    
Name:________________________________ Birth Date:___/___/___  CLASS#___________________ 
  
Reason Referred:_______________________________________________________ on ___/___/_____ 
                                                                                                                                                                                    (date) 
Medical Insurance:_____ Medicaid – Number: ______________________________________________

                               _____ Insurance through: _______________________________________________
  
                               _____ None 

---------------------------------------- To be completed by Physician/Provider ----------------------------------
  
Problem Identified:____________________________________________________________________
  
____________________________________________________________________________________
  
Classroom/Home Visitor Recommendations:________________________________________________
    
Initial Treatment:___/___/___                     Treatment Plan:____________________________________
                                  (date) 
Most Recent Follow-Up: ___/___/___                                  ____________________________________ 
	       (date)
Treatment Completed: ___/___/___                                      ____________________________________
                                                   (date)                                   
Next Appointment:___/___/___                                            ____________________________________
                                     (date) 

HEARING:                             
[ ] PURETONE  [ ] TYMPANOMETRY [ ] OTHER:_____________________    Pass  /  Fail  (Circle One) 

VISION:										 Pass / Fail (Circle One)

                                                                                             ______________________________________ 
                                                                                                              (Physician/Provider Signature) 

                                                                                             ______________________________________ 
 Please Return To:                                                                                               (Title) 
                                                                                             ______________________________________ 
 [AFFIX CARD]                                                                                                  (Date) 

                                                                                                      Physician/Provider Name & Address:  

                                                                                             _______________________________________ 
  
                                                                                             _______________________________________ 
  
                                                                                             _______________________________________ 
                                                                                                                                                  (Please Print)