Pediatric Dentistry of Shelbyville
MEDICAL UPDATE FORM
To assist us in keeping your child's medical history up to date, please complete the following:
Child's Full Name
*
First Name
Last Name
Age
*
Gender
*
Male
Female
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone
*
Please enter a valid phone number.
Email
*
example@example.com
School
*
Insurance
Policy's holder's name
*
First Name
Last Name
Employer
*
Dental Insurance
*
Policy holder's Date of Birth
*
-
Month
-
Day
Year
Date
Emergency Contact
*
Emergency Phone
*
Please enter a valid phone number.
Is your child having any dental problems? If yes, What?
*
No
Yes
Has your child had a physical since your last visit? If yes, When?
*
No
Yes
Has your child's medical history changed since the last visit? If yes, How?
*
No
Yes
Does your child have or he/she ever had any if the following (check all that apply):
*
ADD / ADHD
AIDS / HIV
Anemia
Asthma
Autism
Birth Defects
Blood Disorders
Brain Injury
Blood Transfusion
Behavior Disorders
Behavioral Problems
Cancer/Tumors
Cerebral Palsy
Cleft Lip / Palate
Developmental Delay
Diabetes
Emotional Disorder
Epilepsy / Seizures
Endocrine Disorder
Fainting
Frequent Headaches
Heart Murmur
Heart Problems
Hemophilia
Hepatitis
Herpes
High Blood Pressure
Kidney Disease
Latex Allergy
Liver Disease
Lung Problems
Mitral Valve Prolapse
Premature Birth
Radiation Treatment
Rheumatic Fever
Scarlet Fever
Sleep Apnea
Skin Rash
Spina Bifida
Stroke
Syndrome
Thyroid Problems
Tobacco / Alcohol Habit
Tuberculosis
NONE OF THE ABOVE
Other:
If a syndrome, please state:
Is your child taking any medications now? If yes, What?
*
No
Yes
Has your child had any injuries to the face, head, or neck? If yes, When and where?
*
Yes
No
Electronic Signature
Date
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: