Health History Form

    Has your child ever had the following illness? , If so, When??

    Name Yes / No Date
    Chickenpox YesNo
    Measles YesNo
    Diphtheria YesNo
    Malaria YesNo
    Heard Dieases YesNo
    Blood Group YesNo
    Epilepsy YesNo
    Tuberculosis YesNo
    Ear Condition YesNo
    Asthma YesNo
    Allergies YesNo
    Others
    Serious Injury YesNo
    Operation YesNo

    Has your child ever had the following protective measures? , If so, When??

    BCG Vaccination YesNo Polio YesNo Tetanus YesNo Hepatitis A & B YesNo