Health Records
Child’s Name _________________________________ Birth Date _________________
Parent’s Name _________________
________ Phone_______________Address _____________________________________
Physician’s Name ______________________ Phone_______________
Address _____________________________________
Dentist’s Name _________________________ Phone_______________
Address _____________________________________
|
Disease History: |
Date: |
Operations: |
Date: |
|
Whooping Cough |
Tonsillectomy |
||
|
Rubella |
Adenoidectomy |
||
|
Chicken Pox |
Appendectomy |
||
|
Mumps |
Mastoidectomy |
||
|
Measles |
Tubes in Ears |
||
|
Other |
Other |
Any existing illness? Yes___ No___If yes, please explain. ______________________________________________________________________
Any previous illness or injuries? Yes___ No___ If yes, please explain. ______________________________________________________________________
Any hospitalization during the past 12 months? Yes___ No___ If yes, please explain.
______________________________________________________________________Any medication that is long term continuous use? Yes___ No___ If yes, please list them.
______________________________________________________________________Any restrictions on normal physical activities? Yes___ No___ If yes, please explain. ______________________________________________________________________
Any chronic medical condition necessitating dietary supplements or restrictions, medications, or avoidance of allergies? Yes___ No___ If yes, please explain. ______________________________________________________________________
Please list any known allergies
. ________________________________________________________________________Does your child have a history of any of the following?
|
Vision Impairment |
Yes _____ |
No _____ |
|
Hearing Impairment |
Yes _____ |
No _____ |
|
Eye Infection |
Yes _____ |
No _____ |
|
Ear Infection |
Yes _____ |
No _____ |
|
Speech Problems |
Yes _____ |
No _____ |
I certify that my child is enrolled in a regular medical program and has been examined by a doctor within the last 12 months.
| _______________________________ | _______________ |
| Signature of Parent or Guardian | Date |