RSP Pre-Admission Health History

Birthdate:(Required)
Date of last physical/medical examination:(Required)

DEVELOPMENTAL HISTORY ( *For infants and preschool-age children only)

PAST ILLNESSES — Check illnesses that child has had(Required)
PAST ILLNESSES - Include Illnesses (checked above) and specify approximate dates of illnesses:
Illness(checked above)
Approximate Dates
 
Specify any other serious or severe illnesses or accidents:(Required)
Does child have frequent colds?(Required)
List any allergies staff should be aware of:(Required)

DAILY ROUTINES (*For infants and preschool-age children only)

DIET PATTERN: (What does child usually eat for these meals?)

WHAT ARE USUAL EATING HOURS?

Any food dislikes?(Required)
Any eating problems?(Required)
Is child toilet trained?(Required)
Are bowel movements regular?(Required)
Is child presently under Doctor's care?(Required)
Does child take any prescribed medication(s)?(Required)
If yes, what kind and side effects?
Does child use special device(s)?(Required)
If yes, what kind?
Does child use special device(s) at home?(Required)
If yes, what kind?
Date:(Required)