MEDICAL HISTORY FORM
Parent/Guardian First Name:
Parent/Guardian Last Name:
*
Contact Email
Phone Number:
Child's First Name:
Child's Last Name:
Has your child has any serious illness, operations, or accidents?
Yes
No
If yes, please describe :
Are your child's immunizations current?
Yes
No
If no, please fill out the immunization exemption form.
Immunization Exemption Form
Allergies, food or otherwise:
Yes
No
If yes, please explain:
Asthma:
Yes
No
Has had Chicken Pox:
Yes
No
Does your child have Diabetes?
Yes
No
If yes, treatment for us to use:
Ear Infections:
Yes
No
Comments:
Epilepsy/Seizures:
Yes
No
Treatment for us to use:
Comments:
Emotional Issues/Behaviors:
Yes
No
Best Methods for us to use:
Situation of Cause:
Measles:
Yes
No
Mumps:
Yes
No
Urinary Problems:
Yes
No
Comments:
Whooping Cough:
Yes
No
Treatment for us to use:
Any Communicable Diseases (genital herpes, & etc.?)
Yes
No
If "Yes", Please List:
Special considerations due to general physical condition:
Doctor:
Phone:
Date of last Physical Exam:
Is child currently taking medication?
Yes
No
If "Yes", Please List:
Other helpful information:
Please upload any necessary documentation, including the immunization exemption form, if you filled one out.
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