Child's Health History Checklist

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Child's Health History Checklist

The answer to these questions will help us to know if your child has any medical problems. We need this information in case he/she would become ill and we would be unable to reach you right away. Please check the right answer. We will go over the checklist with you when you have finished.

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* Indicates required question

Pregnancy and Birth

Parent's Name *

Your answer

Child's Name *

Your answer

Were there any problems with pregnacy or your child's birth? *

Yes

No

Was his/her birth weight under 5 1/2 pounds? *

Yes

No

Did the baby have any problems in the hospital? *

Yes

No

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