OFFICE OF HEALTH STATUS MONITORING DEPARTMENT OF HEALTH Legal Name of Child: Birthdate: Sex/Race: Worker/Title: Phone No.: Date:
MEDICAL INFORMATION FORM FAMILY OF: [ ] CHILD'S MOTHER [ ]CHILD'S FATHER NAME (Only on Original) RACE BIRTHDATE MARITAL STATUS: (at birth of child) [ ] Married [ ] Separated [ ] Divorced RELIGION [ ]Widowed [ ] Single ADDRESS (Only on Original)
FOR MOTHER OF CHILD, DESCRIBE VERIFICATIONS, INCLUDING DATES OF DIVORCES OR DEATHS:
(CHILD'S) PARENT YEAR OF BIRTH HAIR COLOR EYE COLOR COMPLEXION WEIGHT HEIGHT EDUCATION EMPLOYMENT (include military) HOBBIES, INTERESTS, TALENTS
CHILD'S SIBLINGS OR (PARENT'S BROTHERS/SISTERS) SPECIFY
ADDITIONAL INFORMATION: (Include special characteristics of parent or of relatives, including evaluation of
social functioning and general intelligence)
Source of Information:
08/07/01 PAGE 1 OF 4 PAGES MEDICAL INFORMATION FORM
MEDICAL CONDITION A. CONGENITAL IMPAIRMENTS 1. Club Foot or any orthopedic problem 2. Harelip (cleft lip) or cleft palate 3. Chromosome abnormality 4. Downs Syndrome 5. Hydrocephalus 6. Muscular Dystrophy
Parts of body involved? Age at onset?
7. Spina Bifida 8. Congenital Heart Defect 9. Tay-Sach's Disease B. ALLERGIES 1. Eczema or other skin condition 2. Hay fever or other allergy 3. Drug allergy C. EYE, EAR, DEVELOPMENT DISORDERS 1. Blindness, glaucoma, color blindness or other visual problems 2. Deafness or other ear problem 3. Speech problems 4. Learning disability 5. Retardation: mental or physical
08/07/01 PAGE 2 OF 4 PAGES MEDICAL INFORMATION FORM
Any cause known? What treatment? What medication?
To what drugs?
Special Education? If "yes" indicate age at onset.
Any diagnosis? Hospitalization?
MEDICAL CONDITION D. GENERAL DISORDERS 1. Hemophilia 2. Sickle cell anemia or trait 3. Hypertension (high blood pressure) 4. Stroke 5. Heart attack (coronary) 6. Arthritis
Age at onset? What treatment? Hospitalization?
What kind? Age at onset? What part of body? Age at onset? What treatment?
7. Kidney disease
E. HORMONAL DISORDERS 1. Diabetes
Age at onset? What treatment?
2. Thyroid disorder F. RESPIRATORY DISORDERS 1. Asthma Any cause known? What treatment?
What kind? Age at onset? What part of body? Age at onset? What treatment? Hospitalization?
G. MENTAL AND BEHAVIORAL DISORDERS 1. Schizophrenia 2. Manic depressive 3. Alcoholism or heavy drinking 4. Drug use
Kind, amount, and when taken?
PAGE 3 OF 4 PAGES
MEDICAL INFORMATION FORM
MEDICAL CONDITION H. LYMPHATIC DISORDERS 1. Cancer
COMMENTS What kind? Age at onset? What part of body
2. Other tumors 3. Cystic fibrosis 4. Hodgkins disease I. NERVOUS SYSTEM DISORDERS 1. Multiple sclerosis 2. Huntington's disease 3. Cerebral palsy 4. Seizures or convulsions 5. Epilepsy J. INFECTION, HOSPITALIZATION 1. Repeated attacks of fever with known infection 2. Repeated severe infection necessitating hospitalization 3. Hospitalization, operation, or injury Diagnosis? Age at onset? What treatment? Frequency? Parts of body involved? Age at onset
K. OTHER IMPAIRMENT, ALLERGY DISORDER OR DISEASE
PAGE 4 OF 4 PAGES
MEDICAL INFORMATION FORM