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Child Health Record
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* Indicates required question
Email
*
Your email
Child's Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Gender
*
Choose
Male
Female
Prefer not to say
Current Weight
Your answer
Current Height
Your answer
Pregnancy History
Please answer if child is under 2 years old and prenatal history is known.
High-risk Pregnancy
*
Choose
Yes
No
Did mother take folic acid/prenatal supplements?
*
Choose
Yes
No
Was baby exposed to neurotoxins before birth? (Check all that may apply
Caffeine
Nicotine/cigarettes
Alcohol
Barbiturates
Amphetamines
Inhalants
Marijuana
Cocaine/crack
Opioids/heroin
Pesticides
Other:
Was Mother diagnosed with any of the following? (Check all that Apply)
Ectopic pregnancy
Gestational diabetes
Low amniotic fluid
Preclampsia
Placentia previa
Other:
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