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Your Child's Medical History Update
Child's Name
*
Date of birth:
*
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Please list any medication(s) your child is currently taking
Health History
Please select "Y" for Yes, "N" for No
Y
N
Abnormal Bleeding
Y
N
Any hospital stays
Y
N
Any operations
Y
N
Asthma
Y
N
Cancer
Y
N
Congenital Heart Defect
Y
N
Convulsions/Epilepsy
Y
N
Diabetes
Y
N
Hearing Impairment
Y
N
Handicaps/Disabilities
Y
N
Heart Murmur
Y
N
Hemophilia
Y
N
Hepatitis
Y
N
HIV + AIDS
Y
N
Kidney/Liver Problems
Y
N
Rheumatic/Scarlet Fever
Y
N
Tuberculosis
Y
N
Allergic to any drugs?
Yes
No
If yes, please list:
Any other allergies
Yes
No
If yes, please list:
Please list any major medical problems that your child has had recently that the staff should know about:
Completion
Signature of responsible party/relationship
*
clear
Date
*
+
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