Child Health History Form
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?
5. List any family medical history conditions
Should be Empty: