Medical History Update Form
Notify Kind Kids Dental of any patient medical history updates
Patient name
*
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Other
Preferred pronouns
Has there been a recent change in address in the past 6 months or since your last visit?
*
Yes
No
Has there been a recent change in insurance in the past 6 months or since your last visit?
*
Yes
No
Has your child ever had any of the following medical conditions?
*
*Pre-Med - Amox
*Pre-Med - Clind
*Pre-Med - Other
ADHD
Allergy - Allergies
Allergy - Aspirin
Allergy - Codeine
Allergy - Erythro
Allergy - Hay Fever
Allergy - Latex
Allergy - Other
Allergy - enn/Amox
Allergy - Sulfa
Anemia
Asthma
Autism
Blood Disease
Cancer
Diabetes
Down Syndrome
Excessive bleeding
Fainting
Glaucoma
Head injuries
Heart disease
Heart murmur
Hepatitis
High blood pressure
HIV
Jaundice
Kidney Disease
Liver Disease
Mental disorders
Nervous Disorders
Pacemaker
Pregnancy
Premature Birth
Radiation Treatment
Respiratory Problems
Rheumatic Fever
Rheumatism
Sensory/On Spectrum
Sinus Problems
Special Needs NOS
Stomach Problems
Stroke
Tuberculosis
Tumors
Ulcers
None of these
Other
Please explain:
Does your child have any other health problems or new diagnoses?
*
Yes
No
Is your child taking any new medications or supplements at this time?
*
Yes
No
Has your child had any recent surgeries, medical issues, or hospitalizations since your last visit?
*
Yes
No
Is your child under care of the same pediatrician?
*
Yes
No
Do you have any new dental, airway, or sleep concerns?
*
Yes
No
Any details you'd like to share:
Please read and acknowledge by checking the box:
*
To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any changes inmy health, I will inform the doctors at the next appointment without fail.
Parent/guardian signature
*
Name of parent/guardian completing this form
*
First Name
Last Name
Relationship to patient
*
Parent/guardian email address
*
example@example.com
Continue
Continue
Should be Empty: