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Child Medical Record Form
Child’s Name:
Birthdate:
Father/Guardian Name:
Phone:
Mother/Guardian Name:
Phone:
Primary Physician:
Phone:
Address:
Is your child currently under the supervision of a physician?	Yes No
If Yes Explain:
Please answer ALL of the questions below.
Does your child have any history of vision impairment?	Yes No
Does your child wear corrective lenses?	Yes No
Does your child have a hearing impairment?	Yes No
Does your child wear a hearing- aid?	Yes No
Does your child have a speech impediment?	Yes No
Has your child ever been tested for intellectual disability or developmental delay?	Yes No
Does your child have an IEP?	Yes No
Does your child have an existing illness?	Yes No
Does your child currently take medication?	Yes No
Does your child have allergies?	Yes No
Has your child been diagnosed with an emotional disorder?	Yes No
Has your child been diagnosed with a behavioral disorder?	Yes No
Is your child participating in a behavioral intervention plan?	Yes No
Is your child participating in a reinforcement plan?	Yes No
Please provide any special instructions regarding any medical questions
Please provide any additional information regarding this form.
General Comments:

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