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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 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



Featured Sites:

Cord Blood Registry
March of Dimes
Susan G. Komen

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