Child’s Name Date of Birth Age: Gender: Preliminary Questions (please fill or circle yes/no) Has your child ever had the following illnesses? If so, please give date and explain below: 1.How much did your child weigh at birth: Weight Status at Birth: Ear/Nose/ Rheumatic Heart Measles Scarlet Fever Seizures 2. Has anyone in the family ever had any serious illnesses or abnormalities (e.g. Throat Problems Fever Disease Yes No heart disease, diabetes, cancer, tuberculosis, asthma, etc.) If yes, please Urinary/ Bee Sting Mumps Respiratory Anemia Pneumonia explain: Kidney Problems Allergy 3. Were there any problems with this child immediately after birth? If yes, Muscle/Bone Blood Yes No Chickenpox Tuberculosis Eye Problems Asthma please explain: Problems Pressure 4. Is your child taking any medications every day? If yes, please explain: Yes No Intestinal Diabetes Dates/Explanations: Problems 5. Will medication be needed at school? If yes, please explain Yes No Has your child ever had the following? If yes, please give date and explain. Hospitalizations Operations Serious Injuries Other Health Problems/Illnesses Allergies to Medications (i.e. Penicillin, Sulfa Drugs) Developmental History: Did Child… Focus eyes and follow light or objects with eyes by 2 months? Coo and Gurgle by 3 to 4 months? Sit alone on or before the 8th month? Walk alone on or before the 15th month? Say simple words on or before the 2nd year? Toilet train on or before the 3rd year? Mental development appears normal? Immunization History (please check the one that applies for your child) Is child up to date on all immunizations appropriate for his/her age? Has child received all immunizations possible at this time but has not received all immunizations for his/her age? Has child received no immunizations None of the above. Explain/Comments:
Child’s Name Date of Birth Age: Gender: Preliminary Questions (please fill or circle yes/no) 1.How much did your child weigh at birth: Weight Status at Birth: Yes No 2. Has anyone in the family ever had any serious illnesses or abnormalities (e.g. heart disease, diabetes, cancer, tuberculosis, asthma, etc.) If yes, please explain: Yes No 3. Were there any problems with this child immediately after birth? If yes, please explain: Yes No 4. Is your child taking any medications every day? If yes, please explain: Yes No 5. Will medication be needed at school? If yes, please explain Has your child ever had the following illnesses? If so, please give date and explain below: Measles Ear/Nose/ Throat Problems Scarlet Fever Seizures Rheumatic Fever Heart Disease Mumps Urinary/ Kidney Problems Respiratory Anemia Bee Sting Allergy Pneumonia Chickenpox Muscle/Bone Problems Tuberculosis Blood Pressure Eye Problems Asthma Diabetes Intestinal Problems Dates/Explanations: Has your child ever had the following? If yes, please give date and explain. Hospitalizations Operations Serious Injuries Other Health Problems/Illnesses Allergies to Medications (i.e. Penicillin, Sulfa Drugs) Developmental History: Did Child… Focus eyes and follow light or objects with eyes by 2 months? Coo and Gurgle by 3 to 4 months? Sit alone on or before the 8th month? Walk alone on or before the 15th month? Say simple words on or before the 2nd year? Toilet train on or before the 3rd year? Mental development appears normal? Immunization History (please check the one that applies for your child) Is child up to date on all immunizations appropriate for his/her age? Has child received all immunizations possible at this time but has not received all immunizations for his/her age? Has child received no immunizations None of the above. Explain/Comments:
911a-health-history.docx