Use This Template

Child Medical History Form

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.

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.

Child Medical History Form

Use our child medical history form to gather a child's prior and current medical health history.



  • Patient
  • Internal Staff


  • Incomplete
  • Submitted
  • Processed