Health History UpdateChild’s Name*Date* Date Format: MM slash DD slash YYYY Father’s Full Name*Mother’s Full Name*Home Ph #*Work Ph #*Cell Ph #*Ok to text?*YesNoAddress*Email address for confirmations*1.) Is there anything about your child’s teeth, mouth or jaw that concerns you?*YesNoDo you have any concerns about today’s appointment that you’d like brought to your doctor’s attention?2.) Is your child presently under the care of a physician for any medical reasons?*YesNoIf so, for what?3.) Is your child taking any medications?*YesNo4.) Does your child have a medical condition? (heart murmur, heart defect, etc.) that requires antibiotics before dental treatment?*YesNoIf so, has your child taken the prescribed medication?What?Dosage?When?5.) Is your child allergic to a medicine or other product?*YesNoWhat?6.) Is your child allergic to vinyl, metals or other product?*YesNo7.) Is your child allergic to latex (balloons or other products)?*YesNo8.) Are you on well water?*Do you use bottled water?*YesNoWhat Brand?9.) Are you interested in information on athletic mouth guards?*Signature of parent or guardianPhoneThis field is for validation purposes and should be left unchanged.
