Medical History Assessment

Medical History Assessment
PRINCIPAL PURPOSE: Information obtained is used to (1) Note special program considerations or restrictions on child participation (2) execute emergency medical procedures for chronic illnesses/conditions. DISCLOSURE: Information is voluntary; however, if information is not provided, individuals may not be able to participate in community activities
Parent/Guardian Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Name of Child

First NameLast Name
Date of Birth

MonthDayYear
Date
Sex

MaleFemale
Does your child have ongoing medical concerns? (If yes explain circumstances and current status)
Medical History

Type a question

	Yes	No
Any hospitalizations or operations
Allergies to medicine, insect bites or food
Speech or development delays
Vision Problems (glasses or contacts)
Ear or hearing problems
Seizures or Convulsions
Dizziness or fainting with exercise
Headaches
Head injury or loss of consciousness
Neck or back injury
Asthma or difficulty breathing
Heart or blood pressure problems
Chest pain with exercise
Heat stroke or exhaustion
Broken bones or sprains
Joint injuries (ankle/knee/wrist)
Required restricted physical activity
Diabetes
Cancer
Dental or orthodontic braces
Learning problems
Sleep problems
Behavioral problems
ADD/ADHD
Autism Spectrum Disorder
Other (please list below)

Ongoing Medications