MEXICAN SOCIAL SECURITY INSTITUTE

SOCIAL SECURITY AND SOCIAL SOLIDARITY

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MEDICAL EVALUATION FORM
Date of issue
DD / MM / YY
(Pre-filled nursery staff)
( , Nursery Data X

Nursery number

Medical support unit KINDERGARTE

Director of the day care center N SEAL
Paternal surname Mother's last name Name(s)

Child's data
Name of child
Paternal surname Mother's last name Name(s)

CURP of the child Social Security Number

Reason for requiring medical evaluation:
Well-child check-up - General disease Infectious disease Accident or emergency care
Food monitoring □ Other □ Specify
Description of the health condition presented

RESULTS OF THE MEDICAL ASSESSMENT

(To be filled out by the treating physician)

Age Weight Size PC T° FC FR

Does the child qualify for day care? YES NO Temporary suspension of service Number of days of suspension
The temporary suspension may not exceed 90 days. Suspension
days are counted in calendar days.

Definitive suspension of he service Justification

Does the child need medical reevaluation? YES Justification

Date for revaluation
NO DD MM YYYYY

Do you need a consultation? YES □ Specialty

NO -

Instructions for determining whether a child is healthy enough to attend day care center
a) The treating physician shall be responsible for determining the child's health conditions to attend day care.
b) The child must be able to integrate himself/herself into the pedagogical and assistance activities of the day care center.
c) That the child has the immunization schedule according to his/her age.
d) If the child has a condition that warrants temporary suspension, the treating physician must follow up and specify a date for reevaluation.

Temporary suspension
Definitive suspension
1. Communicable diseases 2. Non-communicable diseases
Any disease, due to a specific infectious agent or its toxic Clinical entity characterized by the absence of a causal A non-curable clinical disease or entity that may or may not be due to a
products, that is transmitted to a susceptible reservoir or microorganism and determined by the interaction of pathogenic agent, which in the short or long term, both in latency and evolution,
host. Transmission can be direct from an infected person environmental and personal risk factors, which may represents a threat to the safety and/or integrity of the child as well as that of
or animal, or indirect via a plant, animal (intermediate cause functional limitation or imply, by their nature, a others, or which requires specialized technical medical care and attention within
host), vector or contaminated material. threat to the integrity of the child, eventually curable or the day care center.The child's safety and/or integrity, as well as that of others,
controllable depending on the condition, the patient's or which requires specialized medical attention and technical care within the day
condition and access to health services. care center.

1.1 The child shall be admitted to day care until the child 2.1 Admission or incorporation into day care will Seizures or epilepsies not treatable or unresponsive to treatment. Chronic
is asymptomatic, the condition is controlled or the depend on whether the health condition is resolved or is degenerative conditions that compromise ventilation, causing respiratory failure
infectious-contagious period has ended, and the child under documented control and does not represent any or requiring oxygen, ventilatory or nebulization support.
poses no risk to the health of the child or others in the risk to the health of the child or others in the day care Diseases with circulatory compromise or congenital heart disease with
day care center. center. untreatable dyspnea or heart failure or without response to treatment.
1.2 Any case with a communicable disease must have a 2.2 Any wound or loss of skin continuity must be When the nutritional contributions of the diet indicated by the treating physician
medical clearance to join the day care center. healed upon admission or incorporation of the child to for the child cannot be covered by the diet provided in the day care center.
1.3 The days of suspension of service and the date of day care. Any permanent or long-term condition requiring parenteral enteral feeding.
re-evaluation, if warranted, must be specified. 2.3 Any condition that hinders movement or requires When the natural process of the disease requires a recovery time of more than
immobilization and/or rest (by medical indication), until it three months.
is resolved or does not represent a risk to the child, to Dissocial disorders with aggression (self or heterodirected) not treatable or
perform the activities of the day care center. unresponsive to treatment.
2.4 Any transient condition requiring enteral or
parenteral feeding.

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(continued)
(To be filled out by the treating physician)
Disability

Does the child have a disability?

(Continued in the diagnostics section)

Slight Moderate

Physical or Specify
Motor Specify
Intellectual
Specify
Sensory
Specify
Mental or
psychosocial
NO
Do you need to attend a rehabilitation program?
YES Specify

(The insured user must submit to the day care center, every six months, a document certifying
his/her attendance to the rehabilitation programs indicated by the treating physician).
NO □
YES - Specify
Do you require prostheses, orthoses or functional aids?

Criteria for classifying disability status

Disability status
Dependence to perform basic functions
according to their chronological age
Physical or Motor
Mild disability Moderate disability
With ability to perform basic functional activities, even if they are
Requires support to perform basic functional activities.
not performed efficiently.

With active movement against gravity, applying resistance and Muscle paralysis, visible or palpable contraction, or active movement
Muscle weakness of extremities
with normal muscular strength. eliminating gravity.

Alteration in the nose, mouth, pharynx and/or larynx that allows
Disorder in the structures involved in voice
communication, without affection in respiratory mechanics,
and speech
chewing or swallowing. May or may not require speech therapy.
Alteration in nose, mouth, pharynx and/or larynx requiring therapy to
establish functional communication. No affection in respiratory mechanics,
chewing or swallowing. With speech therapy.

Intellectual developmental disorder
1
1
( ¡
5 Less than 12 months difference between chronological age and
Specific language disorders
With independence to perform functions according to their
chronological age. No aggressive behavior.
composite linguistic age (expressive language and receptive
language). May or may not require speech therapy.
Who requires support to perform functions according to their chronological
age. With functional communication and no aggressive behaviors.
Difference of 12 m. between chronological age and expressive language,
6 m. of difference between chronological age and receptive language or
12 m. of difference between chronological age and composite linguistic
age. With speech therapy.

Auditory Hearing loss with audiometry value greater than 41 dB. Unilateral or
Hearing loss with audiometry value of less than or equal to 40 dB bilateral hearing loss.
i
Mild visual weakness. It does not require orientation and mobility Severe visual weakness and blindness. Requires orientation and mobility
Visual
(/ therapy. therapy.
That their behaviors are not aggressive and allow the execution of That their behaviors can be addressed by the child care staff and not
Mental or psychosocial

Attention deficit disorder with or without

hyperactivity disorder
Autism spectrum disorder
Aggressive behaviors towards themselves
and others, defiant and oppositional
behaviors.
daily activities in the nursery. May or may not require Tx.
Specialized external.
When their behavior patterns do not affect the dynamics of the
child care center. No aggressive behavior. Whether or not Tx.
Specialized external.
Low Tx. external.
aggressive. Low Tx. Specialized external.
When their behavior patterns can be addressed by child care staff without
putting themselves or others at risk. With specialized external Tx.
Low Tx. Outpatient, without becoming a psychiatric patient that the day
care staff cannot provide the specialized care and attention required.

Diagnostics
ICD 10 Code

Diagnosis 1
Diagnosis 2
Diagnosis 3

Indications for day care

( HEALTH PROFESSIONAL DATA

Date on which the valuation was
performed
DD MM YYYYY

The appraisal was performed by:

IMSS Private physician
Medical unit:
Name Name
SEAL OF
Registration THE FMU Professional license
Professional license Specialty
Specialty Specialty certificate

SIGNATURE SIGNATURE
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This document must be free of erasures or alterations.