marketingbysos.com - Health History Update Form

Health History Update
First Name:
Last Name:
Birthdate:

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Address
Pediatrician
Does your child require premedication for dental treatment (prosthetic heart valve or similar)?

YesNo
Are your child's immunizations up to date?

YesNo

Please list all medications your child is currently taking in the highlighted fields and check the box next to them.

	Medications	Check the box
1
2
3
4
5
6
7
8

Check any allergies your child has to any of the following. Add any not listed under OTHER and check the box next to them

AnestheticIbuprofen (Motrin)LactoseGluten/WheatLatexAspirinIodineCaseinShellfishPet fur/danderCephalosporinsPenicillin/AmoxicillinSoyEggsCodeineSulfa/SulfonamidesPeanutsStrawberriesErythromycinTetacyclineTree NutsBananasOther
Has your child had any of the following conditions or treatments within the last 2 weeks?

Acid Reflux (GERD)Bladder InfectionEmotional disturbancePneumoniaAdenoiditisBleeding disorderEpilepsyPregnancyADHDCeliac DiseaseFifth DiseaseRespiratory ProblemAllergies/Hay FeverCerebral PalsyHand, Foot & MouthSensory IssuesAnemiaColdHearting/Speech problemSinus ProblemAnxiety disorderHeart MurmurStrep ThroatAsperger's SyndromeDiabetesInfluenza (Flu)TonsillitisAsthmaEar InfectionKawasaki DiseaseUrinary Tract infectionAutismEczemaMouth UlcersWhooping Cough
Please elaborate as necessary for any checked conditions:
Are there any other conditions or treatments not listed above?

YesNo
Please describe:
Has your child had his/her tonsils removed?

YesNo
Has your child had his/her adenoids removed?

YesNo
Are there any other recent and/or pending surgeries?

YesNo
Please list:
Please list any of your child's recent positive or negative medical/dental experiences that you feel are relevant:
Dental History Update
Has your child had any injuries to his/her head, face, mouth or teeth?

YesNo
Dates and specifics:
Are there any particular concerns with your child's teeth or with his/her dental and oral health?

YesNo
Please explain:
Parent/Guardian signature:

Clear
Date

MonthDayYear
Date
Should be Empty:

Health History Update

Dental History Update