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 any of the following forms completed at a different time, a fee will be charged to complete these forms:
- Day Care forms
- Head Start forms
- FMLA papers
- Driver’s Permit
- Camp forms
- PIAA forms (when and Interim Health History is indicated)
- College forms - $10 fee will be charged for College forms requested at any time since these forms are comprehensive and require significant time for review and completion.
Please allow 7 to 10 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 from that needs to be picked up on the same day. 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 MyCHOP.
- 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.
- Family History Form
- Female Adolescent Health Questionnaire — for girls age 12-15
- Older Female Adolescent Health Questionnaire — for girls age 16-17
- Male Adolescent Health Questionnaire — for boys age 12-15
- Older Male Adolescent Health Questionnaire — for boys age 16-17
- Nutrition Questionnaire — for children 9 & 12 months
- Nutrition Questionnaire — for children 15 & 18 months
- Nutrition Questionnaire — for children age 2-11
- Nutrition Questionnaire — for children age 12 and older
- SCARED Questionnaire Child Version (English)
- SCARED Questionnaire Parent Version (English)
- SCARED forma para los padres (Español)
- SCARED forma para niños (Español)
- Child Health Report — available through electronic medical record; please call the office to request form
- PIAA Comprehensive Initial Pre-Participation Physical Evaluation — available through electronic medical record; please call the office to request form
Release of information
- HIPAA English — Authorization to release/obtain information
- HIPAA Spanish — Authorization to release/obtain information (en Español)