Health History (3 and over)

Last Name

First Name

Nickname

Date of Birth

Minor/Child’s Health History

Minor/Child’s Previous Physician

City/State

Phone

Has minor/child had any history of/or difficulty with any of the following?

Immunizations up-to-date?
Yes
No

Medications Minor/Child is on

Allergies of Minor/Child

Hospitalizations and/or Surgeries

Date

Reason(s)

Hospital

Add another?

Family History

Has member of the family or close relative had any of the following?

Sports Participation Questions

Has your child ever fainted/passed out DURING exercise?
Yes
No

Has your child ever fainted/passed out or nearly passed out AFTER exercise?
Yes
No

Has your child ever had chest discomfort, pain or pressure DURING exercise?
Yes
No

Does your child’s heart race (palpitations) or skip beats DURING exercise?
Yes
No

Have you been told that your child has heart disease, a heart murmur, high blood pressure or high cholesterol?
Yes
No

Has any family member died of heart problems or a sudden and unexpected death before age 50?
Yes
No

Does anyone in your family have Marfan’s syndrome?
Yes
No

Social History

Who is living in your home?

Does your child use a
Car seat
Seat belt

Is your child in daycare?
Yes
No

Are there any smokers in the house?
Yes
No

Are there any firearms in the house?
Yes
No

Was your house built before 1978?
Yes
No

Is there any peeling paint in the house?
Yes
No

Do you have smoke detectors and a fire escape plan?
Yes
No

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Date

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