Health History Update
Patient Name:
*
First Name
Last Name
Date of Birth:
*
-
Month
-
Day
Year
Date
Age:
*
Gender
*
Male
Female
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Name:
*
First Name
Last Name
Cell Phone:
*
Format: (000) 000-0000.
General Health
*
Excellent
Good
Fair
Poor
Pediatrician:
*
Date of Last Exam:
*
Is the child being treated for anything now?
Are you Pregnant?
Medical Health History
Medical Health History
Epilepsy/Convulsions
Heart trouble/murmur
Speech problem
Liver disease/jaundice
ADD/ADHD
Cerebral palsy
Blood Disorder
Cancer/tumor/leukemia
Diabetes
Developmental delay
Hearing problem
Thyroid problem
HIV/AIDS
Asthma/lung problem
High Blood Pressure
Kidney/urinary problem
Emotional Problems
Hepatitis
Rheumatic fever
Autism
Bleeding concerns
Allergies
Allergies
*
Penicillin
Codeine
Novocaine
Latex/Rubber
Other
Does child have any other medical conditions that aren’t listed
Does child have any allergies
Current Medications:
*
Surgeries/Major Operation
verify the above information is correct and give my consent for treatment
Parent/Guardian Signature:
*
Date:
*
-
Month
-
Day
Year
Date
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