Child’s History Does your child have, or has he/she ever had: Chickenpox Yes No When   Frequent ear infections Yes No Explain   Problems with ears or hearing Yes No Explain   Nasal allergies Yes No Explain   Problems with eyes or vision Yes No Explain   Asthma, bronchitis, bronchiolitis, or pneumonia Yes No Explain   Any heart problem or heart murmur Yes No Explain   Anemia or bleeding problem Yes No Explain   Blood transfusion Yes No Explain   Frequent abdominal pain Yes No Explain   Constipation requiring doctor’s visits Yes No Explain   Bladder / kidney infection Yes No Explain   Bed-wetting (after 5years old) Yes No Explain   (For girls) Has she started her menstrual periods? Yes No Explain   (For girls) Are there problems with her period? Yes No Explain   Any chronic or recurrent skin problem Yes No Explain   (acne, eczema, etc.) Explain Frequent headaches Yes No Explain   Convulsions or other neurological problem Yes No Explain   Diabetes Yes No Explain   Thyroid or other endocrine problem Yes No Explain   Any other significant problem Yes No Explain   Use of alcohol or drugs Yes No Explain  
Child’s History Does your child have, or has he/she ever had: Chickenpox  Yes  No When Frequent ear infections  Yes  No Explain Problems with ears or hearing  Yes  No Explain Nasal allergies  Yes  No Explain Problems with eyes or vision  Yes  No Explain Asthma, bronchitis, bronchiolitis, or pneumonia  Yes  No Explain Any heart problem or heart murmur  Yes  No Explain Anemia or bleeding problem  Yes  No Explain Blood transfusion  Yes  No Explain Frequent abdominal pain  Yes  No Explain Constipation requiring doctor’s visits  Yes  No Explain Bladder / kidney infection  Yes  No Explain Bed-wetting (after 5years old)  Yes  No Explain (For girls) Has she started her menstrual periods?  Yes  No Explain (For girls) Are there problems with her period?  Yes  No Explain Any chronic or recurrent skin problem  Yes  No Explain (acne, eczema, etc.) Explain Frequent headaches  Yes  No Explain Convulsions or other neurological problem  Yes  No Explain Diabetes  Yes  No Explain Thyroid or other endocrine problem  Yes  No Explain Any other significant problem  Yes  No Explain Use of alcohol or drugs  Yes  No Explain