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.

At Children’s Hospital of Philadelphia and the CHOP Primary Care Network, we are happy to help you get the medical records you need, when you need them.

In most cases, your child must have been seen at a CHOP Primary 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.

Sports clearance forms must include a sports clearance evaluation (separate from the annual visit) after June 1 of the current sports season.

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 in a hurry or completed at a different time outside of an office visit, we will do our best to accommodate you. A fee may be charged. Please allow 5-7 business days to have these forms completed.

Please note: If you would like the completed health forms sent to a recipient other than yourself (parent/legal guardian), a HIPAA release form may be required. Your office can provide more information.

Additional information:

• 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 the message through and our staff will be able to complete your request. 
• There is no charge for completing medication dispensing forms or for copies of immunization records. These forms are available through MyCHOP. You may also contact the office directly and request a copy.
• If you are submitting a request a utility bill extension, please read our Utility Assistance Policy. We will assist with one request for extension.
• Driver’s Permit Physical Examination Forms (PDF). Patient must be present to sign the form in front of the physician. Please call the office in advance for a time that is mutually convenient for this meeting. An exam may be required. Note: Pennsylvania driver's permit forms require that the physical exam be done within six months of your child turning 16 and the examination form is good for one year. 

Downloadable forms

Please note additional forms are available in MyCHOP. If you don’t see what you’re looking for here, ask your care team.

Sports

• Pennsylvania Interscholastic Athletic Association, Inc. (PIAA) Forms — includes PIAA Comprehensive Initial Pre-Participation Physical Evaluation form (see “CIPPE” form). The PIAA requires all athletes to have a physical exam after June 1 for completion of the PIAA sports clearance form for the following school year.
• Pop Warner Forms
• NJ Department of Education Student Athlete Forms — Includes pre-participation physical exam forms and more

New patient forms 

• New Patient Registration Form (PDF)

HIPAA release of information forms

• HIPAA English (PDF) — Authorization to release/obtain information 
• HIPAA Spanish (PDF) — Authorization to release/obtain information (en Español) 

Interim health forms

• Interim Health Form (PDF) 

Medical consent authorization forms

• Medical Consent Authorization (PDF)
• Autorizacion de Consentimiento Medico (PDF)

NICHQ Vanderbilt ADHD assessment scale

• For Parents: FOLLOW-UP Form
• For Teachers: FOLLOW-UP Form

For additional information

• Obtaining medical records
• Protecting patient privacy