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 Primary Physician
Child's Current Medication/Supplements
History Of Seisures
History Of Ear Infection ?
Does the child have Ear Tubes ?
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