BALA KIDS DENTISTRY MEDICAL HISTORY UPDATE

MEDICAL HISTORY UPDATE
Since one’s health can change overnight, this form is required to be completed the day of the appointment. Thank you for your understanding.
Patient Name *

First Name Last Name
Date of Birth: *

Month Day Year
Date
1. Any medical changes? *

Yes No
If yes, provide details.
2. Any recent hospitalizations/major surgeries? *

Yes No
If yes, provide details.
3. Allergic to any medications? *

Yes No
If yes, provide details.
4. Currently taking any medications? *

Yes No
If yes, provide details.
5. In the past two weeks, has the patient experienced any symptoms of fever, coughing, shortness of breath, loss of smell or taste? *

Yes No
If yes, provide details.
6. In the past two weeks, has the patient tested positive, been exposed or currently waiting on results for COVID-19? *

Yes No
If yes, provide details.
Consent for clinical pictures to be taken of mouth/teeth for patient records: *

Yes No
Primary questions or concerns:
Signature: *

Clear
Date: *

Month Day Year
Date
Name of Adult Accompanying Patient *
Relationship to Patient: *
Should be Empty: