3-HEALTH HX FORM

CHILD HEALTH HISTORY
Child's Name
Date of Birth

MonthDayYear
1. Has your child had any medical conditions/diagnoses (asthma, diabetes, autism, ADHD, etc.)?
Please explain any issues, or indicate "none" or "n/a" if not applicable.
2. Has your child had any surgery (tubes, tonsils, appendicitis, etc.)?
If yes, please indicate all procedures.
3. Is your child currently taking any prescribed medications?
Please list all medications.
4. Is your child allergic to any medications?
List medications
5. List any family medical history conditions
Father
Mother
Brothers
Sisters
What would you like to do next?
Should be Empty:

CHILD HEALTH HISTORY