My ParenTime's Printable Checklists #62a | Family Medical Checklist

Family Medical Checklist
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Name__________________________
Physician_______________________
Physician_______________________
Physician_______________________
Dentist_________________________
Phone___________________________
Phone___________________________
Phone___________________________
Phone___________________________

Blood Type____________Vision____________Hearing____________
Regular Medications___________________________________Dosage___________
Regular Medications___________________________________Dosage___________

Illness
Hospitalizations YES NO DATE COMMENTS

Chicken Pox

Measles

Diphtheria

Mumps

Rubella

Hepatitis

Tonsillitis

Polio

Whooping Cough

Influenza

Pneumonia

Tuberculosis

Allergies

Parents' Medical History: ______________________________________________________

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Illness Hospitalizations	YES	NO	DATE	COMMENTS
Chicken Pox
Measles
Diphtheria
Mumps
Rubella
Hepatitis
Tonsillitis
Polio
Whooping Cough
Influenza
Pneumonia
Tuberculosis
Allergies