| HEALTH HISTORY 1. Child�s Name____________________________Birthdate______________________ 2. Last Physical Examination________________________________________________ 3. Food Allergies_________________________________________________________ 4. Medicine Allergies_____________________________________________________ 5. Illnesses: (please circle all that apply, rather child has had only one occurrence or many) Does your child have any problems with any of these? Allergic to Bee Stings Constipation Lice Convulsions Ringworm Diarrhea Skin Rash Fainting Spells Soiling Frequent Colds Stomach Upsets Frequent Ear Infections Urinary Problem Frequent Sore Throats Worms Has your child had any of these diseases? Asthma Bronchitis Chicken Pox Diabetes Heart Disease Hepatitis Impetigo Measles Mumps German Measles Polio Scarlet Fever Tuberculosis Whooping Cough Other ILLNESSES?_____________________________________________________ 6. Has your child been HOSPITALIZED?_____________________________________ 7. Has your child had any INJURIES with fractures or loss of consciousness? _________ ________________________________________________________________________ 8. Any other members of your family history? ASTHMA___DIABETES___EPILEPSY___ |
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