Medical History Form

Medical History
Child's Full Name*

First NameLast Name
Child's Date of Birth*

MonthDayYear
Date
Is your child currently taking any medications? Please specify*
Does your child have any allergies to medications? Please specify*
Does your child have a latex allergy? Please specify*

YesNo
Do your child have any allergies to dental materials? Please specify*
Is your child under the care of a physician for any medical conditions? Please specify*
Has your child had tonsils and/or adenoids removed?*

NoTonsilsAdenoidsTonsils and Adenoids
Please list any surgeries your child has had:*
Please check if your child has had or currently has any of the following conditions:*

I do not have any of the below conditionsAIDS/HIVAnemiaAsthmaBone DisorderBlood DiseaseBronchitisCancerDevelopmental DisorderDiabetesDizziness or FaintingEmotional ProblemsEndocrine DisorderEpilepyFacial/Jaw/TMJ PainFrequent HeadachesGrowth DisordersHeart ConditionHeart MurmurHearing ImpairedHepatitisHernia RepairHerpes/Cold SoresHives/RashKidney DisorderLiver DisorderMouth BreatherMitral Valve ProlapseNervous/AnxiousProne to coldsProne to ear infectionsProne to sore throatsProlonged BleedingPsychiatric CareRheumatic FeverTonsilitisTrauma to face or JawTuberculosisUlcerVertigoVision Impaired (partial or complete blindness)Other
Guardian's Signature*

Clear
Date*
Should be Empty: