Whether your child is entering daycare or school, or wants to participate in organized recreational activities, you may be asked to fill out a health form detailing your child’s medical history.
At The Children’s Hospital of Philadelphia and the CHOP Care Network, we are happy to help you get the medical records you need, when you need them.
In most cases, your child must have been seen at a CHOP Care Network location for a complete check-up within the past 12 months for us to complete these forms. If this is not the case, you will need to schedule an office visit for your child.
Health forms are completed at the time of your child's physical exam. Please remember to bring the forms to your child’s visit. Your child’s provider will print a health form (including immunizations) at the time of your child’s well visit. This form can be copied and used throughout the year.
If you need a health form completed at a different time, a $10 fee will be charged for all forms completed, regardless of the number submitted. Please allow 3 business days after payment for these forms to be completed.
If you need a health form in a hurry, we will do our best to accommodate you. There is a $20 cash fee for a sports form that is needed the same day. The form must be received in the office by noon (weekdays only), in order for it to be completed by 3 p.m. that day.
There is no charge for completing medication dispensing forms or for copies of immunization records. These can be obtained by contacting the office directly and requesting a copy, and are also available through MyChart.
Driver’s Permit Physical Examination forms will be completed free of charge, but the patient must be present to sign the form in front of the physician. Please call the office in advance for a time that is mutually convenient for this meeting. Note: Pennsylvania driver's permit forms require that the physical exam be done within 6 months of your child turning 16 and the examination form is good for one year.
- HIPAA laws require written authorization for completion of all health forms.
- The Pennsylvania Interscholastic Athletic Association requires all athletes to have a physical exam after June 1 for completion of the PIAA sports clearance form for the following school year.
- Child Health Report (PDF) — used by most PA daycare centers
- PIAA Comprehensive Initial Pre-Participation Physical Evaluation (PDF)
- 2012 Pop Warner Little Scholars Physical Form (PDF)
- New Patient Registration Form (PDF)
- New Patient History Form (PDF)
- Interim Health Form (PDF)
- HIPAA English (PDF) — Authorization to release/obtain information
- HIPAA Spanish (PDF) — Authorization to release/obtain information (en Español)
- Modified Checklist for Autism in Toddlers (M-CHAT English) (PDF) — autism screening questionnaire for children 18-30 months old
- Modified Checklist for Autism in Toddlers (M-CHAT Spanish) (PDF) — autism screening questionnaire for children 18-30 months old (en Español)