Medical Report

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Name of Child *
Name of Child
Birthdate *
Birthdate
Name of Parent or Guardian *
Name of Parent or Guardian
Address of Parent or Guardian *
Address of Parent or Guardian
Medical History
May be completed by parent.
Is child allergic to anything? *
Is child currently under a doctor's care? *
Is the child on any continuous medication? *
Any previous hospitalizations or operations? *
Any history of significant previous diseases or recurrent illness? *
Diabetes? *
Convulsions? *
Heart Trouble? *
Asthma? *
Does the child have any physical disabilities? *
Any mental disabilities? *
Acknowledgement of Parent or Guardian
You acknowledge that all information provided in the Children's Medical Report Form is complete and accurate to the best of your ability.
Parent or Guardian Name *
Parent or Guardian Name
Parent or Guardian Contact Number *
Parent or Guardian Contact Number