______________________________ __________________ ________________________                      Child’s Name                                            Birth Date                                 Parent Name

The answer to these questions will help us to know is your child has any medical problems. We need this information in case he/she would become ill and we would be unable to reach you right away. Please circle the right answer.

   Yes    No 1) Were there any problems with pregnancy or your child’s birth?

   Yes    No 2) Was his/her birth weight under 51/2 pounds?

   Yes    No 3) Did the baby have any problems in the hospital?

   Yes    No 4) Has your child ever been in the hospital overnight?

   Yes    No 5) Is your child taking any medicine?

   Yes    No 6) Any allergies or reactions to medicine, DTP, or other shots or insects?

   Yes    No 7) Has your child had asthma or wheezing?

   Yes    No 8) Does your child have speech or hearing problems?

   Yes    No 9) Has your child had more than two ear infections in a year?

   Yes    No 10) Has your child had tonsillitis?

   Yes    No 11) Does your child have trouble with his eyes or seeing?

   Yes    No 12) Has your child had a bladder or kidney infection? 

   Yes    No 13) Does he/she have burning when urinating?

   Yes    No 14) Does he/she have seizures, fits or shaking spells?

   Yes    No 15) Have you ever been told your child has a heart murmur?

   Yes    No 16) Is your child able to play as hard as other children?

   Yes    No 17) Has your child ever had a bumpy, swollen reaction to the TB skin test?

   Yes    No 18) Has your child ever been with anyone having TB?

   Yes    No 19) Has your child ever had worms?

   Yes    No 20) Does your child scratch his/her genitals?

   Yes    No 21) Is your child a hemophiliac (free bleeder)?

   Yes    No 22) Is your child on a heart monitor?

   Yes    No 23) Does your child have tubes in his/her ears?

   Yes    No 24) How old was your daughter when she had her first period?

   Yes    No 25) Does she have any problems with her period?

   Yes    No 26) Is your child in a special education class at school?

   Yes    No 27) Does your child get along well with other children?

   Yes    No 28) Is he/she usually happy?

   Yes    No 29) Does your child have any special problems not indicated above?

   Yes    No 30) When did your child last see a doctor: ________________      _________ Month Year