Child's Name________________________Sex______Birth Date____________________
Address______________________________________Phone Number__________________
Height__________________________ Weight______________________
Please list any serious illness, operation, or injury, and the age incurred:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Immunization Record
_____ Birth Hepatitis B #1 *
_____ 1 mo. Hepatitis B #2 *
_____ 2 mo. DTP #1, Polio #1, Hib #1 *
_____ 4 mo. DTP #2, Hib #2 *
_____ 6 mo. DTP #3, Hib #3 *, Hepatitis B #3 *
____ 15 mo. Measles, Mumps, Rubella, DTP #4, Polio #3, Hib #4 *
* Optional: Hepatitis B #1, #2, #3 and HIB #1, #2, #3, #4
Please list any abnormalities in the following:
Eyes________________________________ Throat________________________________
Ears________________________________ Heart_________________________________
Nose________________________________ Blood Pressure________________________
_______________________________________ Date_______________________________