EmailMe Form - Health History

Child's Name *

First Last

Date of Birth *

MM / DD / YYYY

Were there any problems with pregnancy or your child's birth? *

Yes

No

If you selected yes above, please explain:

Was his or her birth weight under 5 1/2 lbs.? *

Yes

No

Did he or she have any problems as a newborn in the hospital? *

Yes

No

Has your child ever been hospitalized overnight? *

Yes

No

If you selected yes above, please explain:

Does your child have any special problems of which staff members should be aware? *

Yes

No

If you selected yes above, please explain:

Parent/Guardian Signature *

First Last

Please enter your (parent/guardian) name above to sign electronically and indicate that the provided health history is complete.

Date *

MM / DD / YYYY