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 $5 fee will be charged for all forms completed, regardless of the number submitted (per child). 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 rush fee for a form that needs to be picked up within 24 hours. No rush requests will be accepted on Saturdays.
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.
- 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.
- Female Adolescent Health Questionnaire (PDF) — for girls age 12-15
- Older Female Adolescent Health Questionnaire (PDF) — for girls age 16-17
- Male Adolescent Health Questionnaire PDF) — for boys age 12-15
- Older Male Adolescent Health Questionnaire (PDF) — for boys age 16-17
- Nutrition Questionnaire (PDF) — for children age 2-11
- Nutrition Questionnaire (PDF) — for children age 12 and older
- Child Health Report (PDF) — used by most PA daycare centers
- New Patient Registration Form (PDF)
- Interim Health Form (PDF)
- 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)
- HIPAA English (PDF) — Authorization to release/obtain information
- HIPAA Spanish (PDF) — Authorization to release/obtain information (en Español)