Sutton - Medical History Form (Pediatric Dentistry)

Medical History Form (Pediatric Dentistry)
Patient's Name:*
DOB:*
Physician/Specialists
Last seen by primary care physician/pediatrician
Reason
Most recent physical exam*
YesNo
YesNo
Please list any specialists your child has seen (i.e. cardiologist, ENT, etc.)
Name
City, State
Reason
Name
City, State
Reason
Name
City, State
Reason
Medical History
YesNo
Please explain:
YesNo
List any medication allergies and reaction:
YesNo
Please explain:
YesNo
Please list:
YesNo
Please explain:
YesNo
YesNo
SeldomOften
YesNo
AnemiaBleeding DisorderDiabetesHyperactivity/ADD/ADHDLatex Allergy/SensitivityPhysical handicapAsthmaBone DisorderEndocrine DisorderHeart Ailment or MurmurLiver Problems/HepatitisPositive for HIVAutism/ Asperger's SyndromeCleft PalateEpilepsy/SeizuresIntellectual DisabilityMalignancies/LeukemiaRadiation TreatmentRheumatic FeverSpeech Problem
Please comment on any problems that were checked in the above areas:
YesNo
AnyMondayTuesdayWednesdayThursdayFriday
AnyEarly/Late Morning (8:00am-12:00pm)Early Afternoon (12:00pm-3:00pm)Late Afternoon (3:00pm-5:00pm)
Should be Empty: