Sutton - Medical History Form (Pediatric Dentistry)

Patient's Name:

DOB:

Physician/Specialists

Last seen by primary care physician/pediatrician

Reason

Most recent physical exam

Has you child received regularly scheduled immunizations?

Has your child ever been seen by a specialist (i.e. cardiologist, ENT, etc.)

Please list any specialists your child has seen (i.e. cardiologist, ENT, etc.)

Name

City, State

Reason

Name

City, State

Reason

Name

City, State

Reason

Medical History

Is your child in good health?

Please explain:

Does your child have any drug allergies?

List any medication allergies and reaction:

Does your child have any allergies (food or environmental)

Please explain:

Is your child taking any medications at this time?

Please list:

Has your child ever been hospitalized or treated in an emergency room for any particular trauma?

Please explain:

Have your child's tonsils and/or adenoids been removed?

Does your child breathe through the mouth?

If yes,

Does your child snore?

Please indicate if your child has had any of the following:

Please comment on any problems that were checked in the above areas:

Would you like to update your preferred appointment day/time?

Preferred appointment day

Time