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?*

Add another childContinue to next form
Should be Empty:

CHILD HEALTH HISTORY