Medical History Form

Medical History
Child's Full Name *

First Name Last Name
Child's Date of Birth *

Month Day Year
Date
Is your child currently taking any medications? Please specify *
Does your child have any allergies to medications? Please specify *
Does your child have a latex allergy? Please specify *

Yes No
Do your child have any allergies to dental materials? Please specify *
Is your child under the care of a physician for any medical conditions? Please specify *
Has your child had tonsils and/or adenoids removed? *

No Tonsils Adenoids Tonsils and Adenoids
Please list any surgeries your child has had: *
Please check if your child has had or currently has any of the following conditions: *

I do not have any of the below conditions AIDS/HIV Anemia Asthma Bone Disorder Blood Disease Bronchitis Cancer Developmental Disorder Diabetes Dizziness or Fainting Emotional Problems Endocrine Disorder Epilepy Facial/Jaw/TMJ Pain Frequent Headaches Growth Disorders Heart Condition Heart Murmur Hearing Impaired Hepatitis Hernia Repair Herpes/Cold Sores Hives/Rash Kidney Disorder Liver Disorder Mouth Breather Mitral Valve Prolapse Nervous/Anxious Prone to colds Prone to ear infections Prone to sore throats Prolonged Bleeding Psychiatric Care Rheumatic Fever Tonsilitis Trauma to face or Jaw Tuberculosis Ulcer Vertigo Vision Impaired (partial or complete blindness)
Guardian's Signature *

Clear
Date *
Should be Empty: