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Child's Medical History

Child's name  
Blood type  

Immunizations/Childhood Diseases

Date Immunization/Disease Reactions Special Notes
       
       
       

Tetanus Shot

Date  
Boosters  

Hospitalizations/Surgeries

Date Reason Special Notes
     
     

Chronic Illnesses (Asthma, Diabetes, etc.)

Date Diagnosis Treating Physician
     
     

Food, Drug, and Other Allergies

Date Developed Allergic to Special Notes
     
     

Growth Tracking

Age/Date Height Weight Percentile Special Notes
         
         
         
         
         

Questions for Next Doctor Visit

 
 
 
 
 

Dental History

Date Procedure Completed Special Notes
     
     

  Date(s) Special Notes
Flouride    
X-rays    
Cavities    
Braces    
     

 


 

Featured Sites:

Cord Blood Registry
March of Dimes
Susan G. Komen


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