Health History Information
Childs First and Last Name
Date of childs last physical exam
/
Month
/
Day
Year
Date
Does your child have any of the following illnesses?
Rows
Check all that apply
Frequent colds
Frequent sore throats
Frequent ear problems
Problem with skin rash
Heart problem
Convulsions
Fainting spells
Diabetes
Asthma
Stomach upsets
Urinary problems
Dental problems
Has your child had any of the following diseases?
Rows
Check all that apply
Date
Bronchitis
Ringworm
Impetigo
Head Lice
Chicken Pox
Hepatitis
Scarlet Fever
Tuberculosis
Measles
Mumps
Poliomyelitis
Whooping Cough
Worms
Has your child had illnesses other than the above? If so please explain.
Is your child on any current medications? If so please explain.
Has your child ever been hospitalized? If so please explain.
Has any other member in your family been seriously ill recently?
Are there any serious behavioral or developmental problems or other special health care needs or accommodations we should be aware of?
Does your child have any allergies of any kind or any food allergies or intolerances? If so please explain.
Is there anything else related to your childs health that you would like us to know?
In the event of a medical emergency, do you have a preferred hospital for your child?
Medical Insurance Company
Policyholder/number
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