HEALTH RECORDDATE RECORDED:
Fill out a copy of this record for each child and share it with your physician.
Name Birthdate
Weight Height
Family history of importance
IMMUNIZATIONS & TESTS
1. Diphtheria-Whooping Cough-Tetanus: 1. ____ 2. ____ 3. ____
Boosters: Td Boosters:
2. Oral Polio trivalent: 1. ____ 2. ____ 3. ____
Boosters: 5. Mumps:
3. Tuberculin tests: 6. Rubella:
4. Measles vaccine: 7. Hemophilus influenza:
CONTAGIOUS DISEASE DATES
Measles: Mumps:
Scarlet Fever: Whooping Cough:
German Measles (Rubella): Chickenpox:
Roseola:
PAST ILLNESS DATES (Significant illnesses)
ALLERGIES
INJURIES
HOSPITALIZATIONS (Dates & diagnoses)
OPERATIONS
Tonsillectomy & Adenoidectomy: _____
Others:
Heart Surgery:
LABORATORY TESTS
Last hemoglobin or CBC (date): Last urinalysis (date):
Last weight & height (date):
Birth defects or special needs of your child:
Additional information:
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