Whitney Child Centre Health Record FormChild's SurnameGiven Name(s)Frequent colds?YesNoTonsillitis?YesNoEar Aches?YesNoStomach Aches?YesNoDoes your child:Vomit easily?YesNoRun high fevers often?YesNoAllergies:Is child allergic?YesNoIf yes, how does it manifest itself?Asthma?YesNoHives?YesNoHayfever?YesNoOther?YesNoOtherPlease describe. What is this allergy caused by?Medical:Has child been to dentist?YesNoHas child had vision tested?YesNoHas child had hearing tested?YesNoResults of TestsPlease indicate if your child has had any of the following communicable diseases (check all that apply):Please indicate if your child has had any of the following communicable diseases (select any that apply): Chicken Pox Rubella Pertussis Meningitis Hepatitis Other If other has been selected, please specify which disease(s):Parent/Legal GuardianDate DD MM YYYY Parent Signature
