3-HEALTH HX FORM

Child Health History Form
Child's Name*
DOB*
1. Has your child had any medical issues and/or hospitalizations (asthma, diabetes, 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
Should be Empty:

Child Health History Form