HEALTH RECORD INFORMATION

PLEASE COMPLETE AND RETURN:

CHILD’S NAME (LEGAL) FIRST MIDDLE MALE FEMALE

BIRTHDAY

SURNAME USED IF NOT SAME AS ABOVE: NO. OF SIBLINGS __

BROTHERS __ SISTERS

_________________________________ OLDER ______________

YOUNGER ___________
FATHER’S NAME _______________________ PHONE _____________

ADDRESS _____________________________ RES ________________

MOTHER’S NAME ______________________ PHONE _____________

ADDRESS ____________________________ RES ________________

DOCTOR ____________________________ PHONE _____________

NAME OF LAST WELL BABY CLINIC ATTENDED:

WHERE
______________________________________________________________________
_______________

ALTERNATE EMERGENCY CONTACT AND PHONE NUMBER

PLEASE FILL IN DATES OF THE FOLLOWING INFORMATION

Whooping Cough Diphtheria
Tetanus Polio Salk
HIB Measles
Mumps Rubella
Varivax Chicken Pox
Vaccine
Pertussis

CHILDHOOD ILLNESSES: MARK IN DATE IF CHILD HAS HAD ANY OF THESE:

MEASELS (RED) HEAD INJURY
RUBELLA ACCIDENTAL
(GERMAN) POISON
CHICKEN POX FRACTURE
MUMPS EAR INFECTION
CONVULSIONS BRONCHITIS
WHOOPING OTHER
COUGH

ALLERGIES

HOSPITILIZATION
______________________________________________________________________
HAS THE CHILD HAD ANY MEDICAL/EMOTIONAL CONDITION REQUIRING OR
RECEIVING TREATEMENT OR SUPERVISION?
______________________________________________________________________
EXPLAIN:
______________________________________________________________________
______________________________________________________________________
______________________________
IS THERE ANY ONGOING MEDICATION?
______________________________________________________________________
_______________
ALBERTA HEALTH CARE #
________________________________________________________________