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Confidential Health Check Form
Name of Baby
Date of Birth
Gender
Male
Female
Address
Postcode
Telephone No
Mobile No
Email
Name of Doctor
Surgery Address
Health Visitor
Birth Weight
Type of Birth
Any other information
Paediatric Health Check 6-8 weeks
Yes
No
GPs Comments
Medical Conditions
Yes
No
Details
Allergies
Yes
No
Details
Recent Vaccinations and Dates
Any reactions?
PTO © Touch-Learn International Ltd 2 of 2 2017 Contraindications to baby massage
Is your baby experiencing any of the following at the moment?
Vaccination in last 3 days
Vomiting
Skin Rash
Infections
Cuts/Wounds
Diarrhoea
Temperature/Fever
Bruising/Swelling
Inflammation
Any other information
Declaration
I confirm that the information supplied is a true record and understand that I should not massage if my baby has experienced any of the above contraindications. I accept full responsibility for the health of my child. I understand all details and information are held in the strictest confidence.
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