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.
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 each health form. Please allow five business days 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 no charge for copies of your child’s immunization records.
- 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.
- Child Health Report (PDF) — used by most PA daycare centers
- PIAA Comprehensive Initial Pre-Participation Physical Evaluation (PDF)
- Pop Warner Little Scholars Physical Form (PDF)
- New Patient Registration Form (PDF)
- New Patient History Form (PDF)
- HIPAA English (PDF) — Authorization to release/obtain information
- HIPAA Spanish (PDF) — Authorization to release/obtain information (en Español)
- 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)