- Medical Record

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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Child Medical Record Form