Medical Information Form
Name __________________________ Age__________________ Sex_____________
Medications
1. Name _______________________________ When was it last taken______________________
When does it need to be taken again__________________ What is it for___________________
2.Name _______________________________ When was it last taken______________________
When does it need to be taken again__________________ What is it for___________________
3. Name _______________________________ When was it last taken______________________
When does it need to be taken again__________________ What is it for___________________
4. Name _______________________________ When was it last taken______________________
When does it need to be taken again__________________ What is it for___________________
Allergies
What foods is the child allergic to
1._______________________________ 2.___________________________________
3._______________________________ 4.___________________________________
What medications is the child allergic to
1._______________________________ 2.___________________________________
3._______________________________ 4.___________________________________
Notes
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
This form may not ask for all needed information, but it is intended as a guide. Some Important information may be missing. No responsibility for missing in formation is claimed by the writer or Department. This page may be copied and edited to correct any missing information, remember you are the baby-sitter and are the one responsible for the correctness and completeness of all information