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 outside of the well visit, a $10 fee will be charged. If you require 3 or more forms a maximum amount of $30 will be charged per family. Please allow 3 - 5 business days after payment for these forms to be completed.
When requesting form completion via MYCHOP, the completed form can be sent to your account to enable you to print, save or send it. Please send message through and our staff will be able to complete your request. There is NO FEE when using MYCHOP.
If you need a health form in a hurry, we will do our best to accommodate you. There is a $20 expedited fee for a form that needs to be picked up within 24 hours. If we receive a rush form on Friday afternoon or Saturday, it will be completed on Monday.
- Child Health Report (PDF) — used by most Pennsylvania 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)
- Assignment of Benefits, Release of Information and Statement of Assistance (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)
- NICHQ Vanderbilt Assessment Scale (PDF) — ADHD screening questionnaire