Child's Information
Name:
Sex of The Child	Female Male
Birthdate of Child: dd/mm/yyyy
Age of Child
Address Where Child Lives
City, State, & Zip Code:
Please use this phone for Confirmation	Home Mother's Cell Mother's Work Father's Cell Father's Work Other
If Other Phone Please List:
Medical History of The Patient
Is Your Child In Good Health Generally	Yes No
Is Your Child Allergic To ANY Medications? - Please List
List ANY Medications That Your Child Is Taking
HAS YOUR CHILD ANY HISTORY OF ANY OF THE FOLLOWING?
Heart Trouble	No Yes
Heart Murmur	No Yes
Asthma	No Yes
Rheumatic Fever	No Yes
Diabetes	No Yes
Kidney Problems	No Yes
Liver Problems	No Yes
Blood Disorders	No Yes
Does Your Child Have Prolonged Bleeding From Cuts	No Yes
Are There Any Physical Handicaps?	No Yes
Explain Any "Yes" Answers
Has Your Child Had Surgery or Hospitalization?	No Yes
If So What? Explain:
Please Explain Any Other Physical or Learning Disability That Has NOT Been Listed or Mentioned

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