Childs Name:
First: M.I: Last:

Parents Name:
First: M.I: Last:

Address:
Street:
City: State: Zip:

Phone and Email:
Home: (###) ###-####
Work: (###) ###-####
Permanent: (###) ###-####
Email:

Is it okay to call you at work? Yes No Not Applicable

Childs Birthday: / / (mm/dd/yyyy)
(Age is an important critera for many studies.)

Childs Gender: Male Female

Race or ethnicity:
African American Asian Caucasian Hispanic
Native American Other I wish not to disclose

Have you ever been diagnosed with asthma?
Yes No No (but I have symptoms)
If yes, what year were you first diagnosed? (yyyy)

Have you ever been diagnosed with allergies?
Yes No No (but I have symptoms)

Please add any additional comments or information here: