Medical History Form
Name Of Person Completing this form
Relationship To Child
Date Form Submitted
Child's First Name
Child's Last Name
Child's Date Of Birth
Child's Age
Gender
Male
Female
Child's Diagnosis
Child's Primary Physician
Child's Current Medication/Supplements
Allergy
History Of Seisures
Yes
No
Parent/Guardian Concerns
History Of Ear Infection ?
Yes
No
Does the child have Ear Tubes ?
Yes
No
Medical/Surgical History (List child's approximate age and reason)
List any relevant information regarding the child's birth here ( Describe any compications or health concern revealed at birth )
List information regarding any Hearing Test, Vision Test and Swallow studies here (Provide Date and Result)
List any relevant information regarding child's Educational History
Submit