Health History Form Birth To 5 Page 3
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3Health History Form
Birth to 5
Child Care:
CIRCLE all that apply
Name of Daycare: ________________________________________________________________________________________________________
Home w/parents
Private home day care
Sitter to home
Family Day care
Other: __________________________________________________________________________________________
_________________________________________________________________
Home occupants: (list ALL)
Parents smokers: (CIRCLE One)
Yes
No
Outside Only
Pets:
None
How many Inside (#)
How many Outside (#)
Dog(s)
Cat(s)
Bird(s)
Reptile(s)
Rodent(s)
Fish(s)
Other: _________________
Page 3 of 3
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Parent category: Medical