Child Health History Form

Please correct the errors described below.


Pregnancy and Birth

Hospitalizations or Serious Illnesses

List any serious and/or unusual illnesses which your child has experienced and the corresponding date(s):

Add Additional Hospitalizations


Family History

provide all boxes where the child or a member of the child's family (parents, siblings, grandparents, aunt, uncles) have had the following illnesses or problems:

General Health

Add Additional Member

Health & Safety Issues

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Your information will be encrypted.