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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)
Other
Guardian's Signature
*
Clear
Date
*
Submit
Should be Empty: