Use our free Child Medical History Form template to gather information about a child’s prior health history and help healthcare providers better treat their pediatric patients. Our comprehensive template includes various aspects about the child’s prior health history, ranging from birth and pregnancy to family and social history. You can easily modify any of the sections by adding your own questions or removing sections entirely if they don’t fit your needs. This version of our medical consent form is intended for children and pediatric patients. We have a template for the adult version of a medical history form available as well.

We also included a simple internal section for your staff to indicate once they’ve added a patient’s medical history to their file. Using workflow statuses and the Entries page, staff members can easily monitor each entry’s progress and status.

All data collected can be made HIPAA compliant with our Enterprise plans after signing our Business Associates Agreement (BAA). Additionally, our data encryption capabilities can help ensure your data is secure both at rest and in transit.

This template includes Person fields and Lookup fields that automatically pull in data from the Healthcare Employee Lookup form, streamlining the process for your internal team. Additionally, the template features Shared With Me views, enabling the physician to easily access any patient entries specifically shared with them in Cognito Forms.

Connected Forms:

This template includes one connected form to help you manage your data more efficiently:

• Healthcare Employee Lookup: The form serves as the source of employee information within your healthcare practice, containing data for physicians, nurses, admin staff, and any other employee roles you have. It’s linked to a Person field in the internal section of the Child Medical History Form, which automatically populates with the name of the staff member who is logged in and making updates. Additionally, a combination of a Person field and a Lookup field connected to this form enables the staff member to select the patient’s physician from a list of employees at the practice and automatically displays the physician’s practice area once selected.

Feel free to customize this template by adding, removing, and editing fields as you see fit. You can style this form as you please or keep your org’s branding consistent with other forms using our Organization Theme feature. You can also directly embed this form onto your practice’s website or portal, if necessary.