Health History Form 

Child's Name *
Child's Name
Birth Date *
Birth Date
A. Prenatal History
1. Was mother's age (under 17 or over 35) at time of birth:
2. Did mother gain (under 20 lbs. or over 40 lbs.) during pregnancy?
3. Did you have prenatal care?
4. Were there any health problems/complications/injuries during your pregnancy?
5. Were there any complications/problems during labor or delivery for the mother or the child?
Was your child full term?
B. HEALTH
1. Did your child have any medical illnesses at birth or within the first year of his/her life?
2. Has your child had a serious accident in the past?
Head Injury?
Does your child seem well most of the time?
4. Has your child ever had any serious health problems?
5. Does your child have health problems now?
6. Is your child taking any medication now (including aspirin, laxatives, vitamins, etc.)?
7. In a year, has your child had as many as three (3) ear infections?
8. Are you concerned about your child's hearing?
9. In a year, does your child have more than 3 colds or sore throat infections with a fever?
10. Are you concerned about your child's eyes or vision?
11. Has your child ever been seen by a medical specialist?
12. Does your child have any special needs?
13. Has your child ever been hospitalized?
14. Is our child allergic to any foods or substances?
C. TOILETING
1. Is your child potty trained?
D. DEVELOPMENTAL HISTORY
6. Can your child feed himself/herself using a spoon and/or a fork?
Can your child wash and dry his/her own hands?
Can your child help with dressing or dress with little assistance?
Can your child speak so that he or she can be understood by others?
Can your child express his or her thoughts and needs easily?
7. Do you have any concerns about your child's appetite or willingness to try different foods?
8. Has your child ever had trouble walking, climbing, reaching, holding on to things?
E. SLEEPING AND EATING HABITS
1. Do you have any special ways of helping your child go to sleep?
2. Does your child cry when going to sleep?
4. Does your child use a pacifier at home? School: Infants and nap time only for toddlers
5. Does your child have a special blanket?
F. Feeding Habits
1. Was your baby breast fed?
2. Is baby still breast feeding?
3. What is your child's present eating habit? Choose one phrase to describe each meal below.
Breakfast
Lunch
Snack
Dinner
4. Has your child had any eating problems?
PLEASE BRING IN YOUR CHILD'S BIRTH CERTIFICATE TO COMPLETE THE REGISTRATION PROCESS
Print Parent Name
Print Parent Name
Parent's Digital Signature
Parent's Digital Signature