Family Child Information Sheet

Family Child Information Sheet

Include names, ages and relationships
Does the child live with the parent(s)? *
Is The Child Less Than 2 Years Old? *

Child’s Birth

(Complete this section if your child is less than 2 years of age)

Was the baby born premature?
Was the birth
During pregnancy did mother smoke, drink or use drugs?
Was (is) the baby


Past Medical History


Has your child ever been diagnosed with any of the following? (Please check all that apply)

Family Medical History

Have child’s parents, brothers or sisters, grandparents, aunts or uncles have ever had any of the following diseases?