Medical History Form

"Child's Medical History"

IMMUNIZATION RECORD____________________________________

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CHILDHOOD ILLNESS. If your child has had any of the following illnesses, please indicate the age (on the line provided) when he or she had them.
_______Measles	_______Smallpox
_______Mumps	_______Diabetes
_______Whooping Cough	_______Heart Disease
_______Poliomyelitis	_______Cholera
_______Rheumatic Fever	_______Pneumonia
_______Scarlet Fever	_______Epilepsy (convulsions)
_______Diptheria	_______Chicken Pox
_______Serious Accidents	_______Asthma, Hay Fever

Special problems ( i.e. speech impediments, handicaps, allergies, hearing and vision disorders or past major illnesses, accidents or operations). List below.

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" It doesn't matter which Organization finds the Children,

 but how fast we find the Children."