Clone of Gregson | Child Medical History

Child Medical History

Welcome!
Name*

First NameLast Name
Medical History
Name of child's physician
Phone Number
Please enter a valid phone number.
Date of last visit

MonthDayYear
Date
Does your child have any allergies to medications?

YesNo
AmoxicillinPenicillinSulfa DrugsCodineOther (see comment)
Describe medicinal allergy:
Any reaction to local anesthetic?

YesNo
Are there other allergies: latex, food, pollen, other?

YesNo
If yes please list medication and reaction:
Has your child had any serious illness or operation?

YesNo
If yes, please explain:
Has your child ever been hospitalized?

YesNo
If yes, when and why?
Does your child have, or has your child ever had, any of the following? Check all that apply

ADD / ADHDAIDS / HIV PositiveAnemiaAsthmaAutismBleeding DisorderBreathing or Sleep DisorderCancerDevelopmental DelayDiabetesDigestive ProblemsEpilepsy or SeizuresFaintingGERD or RefluxHearing ImpairmentHeart MurmurHeart Problems
Describe
Does your child have, or has your child ever had, any of the following? Check all that apply

HemophiliaKidney ProblemsLiver DiseaseNeurological DisorderPsychiatric CareTobacco HabitTuberculosisScarlet / Rheumatic Fever
Any other medical conditions?
Does your child require an antibiotic prior to dental treatment?

YesNo
Female patient: Are you pregnant?

YesNo
Date Due:

MonthDayYear
Date
List all medications your child is taking
Emergency Contact
Name
Relationship
Phone Number
Please enter a valid phone number.
By signing this form, I acknowledge that the information provided is true and accurate to the best of my knowledge.
Signature*

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Signers Full Name

First NameLast Name
Date*

MonthDayYear
Date
Relationship to patient
Should be Empty:

Child Medical History

Welcome!

Medical History

Emergency Contact