Pals Medical Form
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Email *
Child's Name: *
Child's Date of Birth *
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Sex *
Mother's Due Date and Child's Birth Weight *
Does your child have any allergies? Please explain if "Yes" (medication, foods, environmental) *
Has your child had any serious illness, injury or been operated on? If yes, please explain. *
Does your child have either a physical handicap or a chronic illness? If yes, please explain. *
Does your child take medication on a regular basis? If yes, please explain *
Childhood disease history. Please check next to all that apply. *
Required
Were there any problems for mother and/or baby during pregnancy, delivery, or shortly after birth? *
Did your baby require oxygen at the time of birth or shortly after? If yes, please explain. *
Are there any nutrition problems? If yes, please explain. *
Does your child have now or has he/she ever had any of the following behaviors? *
Which hand does your child use? *
Has your child been examined by a dentist? *
Has your child been examined by an eye doctor? *
Does your child wear glasses? *
Family Health History - check all that apply (can be within grandparents, aunts, uncles, as well as mother and father *
Required
Does your child have any behaviors that would make you suspicious of either a hearing or vision problem? *
Please include anything about your child that you consider relevant to his/her adjustment to Pals. Does you have any concerns regarding your child's health? *
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