Child'S Health Record Template
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1Child’s Health Record
Name
Date
DOB
Teacher
Health Information
Allergies
Chronic Conditions
Food
Asthma
Medication
Diabetes
Other
Seizures
Other
Limitations
Developmental
Mobility
Vision
Emotional
Hearing
Other
Other health concerns
Medications
Medication
Medication
Dosage
Dosage
Healthcare Providers
Physician
Address
Phone
Date of Last Evaluation
Dentist
Address
Phone
Date of Last Evaluation
Other
Address
Phone
Date of Last Evaluation
Other health-related information not listed above
Emergency Contact Information
Name
Name
Phone
Phone
Relationship
Relationship
Parent/Guardian Signature
Date
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Parent category: Medical