5. What over-the-counter medicines, does your child take regularly? Vitamins ☐ Herbal medicine (please list) ☐ Other (please list) ☐ None, my child does not take any over-the-counter medicines regularly. ☐ 6. Does your child have any allergic reaction (bad effect) from any of the following? (Check all that apply.) Outside or ☐ Indoor allergies (for example: grass, pollen, cats …) Food Allergies (for example: peanuts, milk, wheat ☐ …) Medicine or shots (immunization). (Please list below.) ☐ No, my child has no allergies that I know of. ☐ Medicine child is allergic What happens when the child takes that medicine to: Example: Amoxicillin Diarrhea (runny poop) 7. Has your child had any of the following diseases? Measles Know ☐Yes ☐No ☐Don’t Mumps Know ☐Yes ☐No ☐Don’t Chicken Pox ☐Yes ☐No ☐Don’t Know Whooping Cough ☐Yes ☐No ☐Don’t Know Rubella Know ☐Yes ☐No ☐Don’t Rheumatic Fever Know ☐Yes ☐No ☐Don’t Scarlet Fever ☐Yes ☐No ☐Don’t Know 8. Please check any of the following medical problems that your child has ever had.
5. What over-the-counter medicines, does your child take regularly? ☐ Vitamins ☐ Herbal medicine (please list) ☐ Other (please list) ☐ None, my child does not take any over-the-counter medicines regularly. 6. Does your child have any allergic reaction (bad effect) from any of the following? (Check all that apply.) ☐ Outside or Indoor allergies (for example: grass, pollen, cats …) ☐ Food Allergies (for example: peanuts, milk, wheat …) ☐ Medicine or shots (immunization). (Please list below.) ☐ No, my child has no allergies that I know of. Medicine child is allergic to: What happens when the child takes that medicine Example: Amoxicillin Diarrhea (runny poop) 7. Has your child had any of the following diseases? Measles ☐Yes ☐No ☐Don’t Know Mumps ☐Yes ☐No ☐Don’t Know Chicken Pox ☐Yes ☐No ☐Don’t Know Whooping Cough ☐Yes ☐No ☐Don’t Know Rubella ☐Yes ☐No ☐Don’t Know Rheumatic Fever ☐Yes ☐No ☐Don’t Know Scarlet Fever ☐Yes ☐No ☐Don’t Know 8. Please check any of the following medical problems that your child has ever had.
healthlittoolkit2-tool11b.docx