Child Health History
Today's Date
-
Month
-
Day
Year
Date
Child's Name
*
First Name
Last Name
Gender
*
Male
Female
Birth date
*
-
Month
-
Day
Year
Date
Age
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home or Cell Phone
*
-
Area Code
Phone Number
Work Phone
-
Area Code
Phone Number
Email
*
example@example.com
In Case of Emergency, Please Notify:
*
First Name
Last Name
Emergency Contact Relationship
*
Emergency Contact Phone
*
-
Area Code
Phone Number
Pediatrician Name
*
First Name
Last Name
Pediatrician Phone
*
-
Area Code
Phone Number
Medical Information
High or low blood pressure?
*
Yes
No
Elevated blood cholesterol?
*
Yes
No
Diabetes?
*
Yes
No
Chest pain?
*
Yes
No
If yes, explain:
More info about chest pain
Family history of heart disease?
*
Yes
No
Joint problems?
*
Yes
No
If yes, explain:
More info about joint problems
Asthma or other respiratory problems?
*
Yes
No
If yes, explain:
More info about respiratory problems
Severe headaches or dizziness?
*
Yes
No
If yes, explain:
More info about headaches or diziness
Musculoskeletal problems or disorders?
*
Yes
No
If yes, explain:
More info about musculoskeletal problems
Recent Surgeries?
*
Yes
No
If yes, explain:
More info about recent surgeries
Any sustained injuries or illnesses?
*
Yes
No
If yes, explain:
More info about sustained injuries or illness
Epilepsy?
*
Yes
No
Arthritis?
*
Yes
No
Difficulty with any form of physical exercise?
*
Yes
No
If yes, explain:
More info about difficulty with exercise
Currently taking any medication?
*
Yes
No
If yes, explain:
More info about current medications
Allergies?
*
Yes
No
If yes, explain:
More info about allergies
Has your doctor ever advised your child not to exercise?
*
Yes
No
If yes, explain:
More info about doctor advise not to exercise
Does your child exercise regularly now?
*
Yes
No
If so, please list activities and estimate frequency:
More info about activities and frequency
Are there any medical reasons your child should not take part in physical activity?
*
Yes
No
If yes, explain:
More info about medical reasons not to take part in physical activity
Child's Vaccination Status
Yes
No
Please list any medical conditions your child may have that would affect taking part in physical activity.(For example, asthma, allergies, diabetes, currently taking medications, etc.)
More info about your child
Date
-
Month
-
Day
Year
Date
I, the parent/guardian of the aforementioned child, acknowledge the above information to be true and accurate. To the best of my knowledge, I have given all relevant information regarding my child’s health and ability to participate safely in an exercise program.
*
Signature
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