NEW Dentrix Medical History Form + COVID

Patient Medical History Form
Patient's Full Name*

First NameLast Name
Gender*
Date of Birth*

MonthDayYear
Date
Child's Physician*
Date Last Seen by Physician*

MonthDayYear
Date
Is Your Child Presently Under the Care of a Physician for any Medical Reason?*

YesNo
If so, for what?
Is Your Child Currently Taking Any Medication?*

YesNo
If so, what?
Has Your Child Ever Been Hospitalized or had Surgery?*

YesNo
If so, for what?
Is Your Child Allergic to any Food or Medicine?*

YesNo
If so, what?
Has Your Child Had a History Of:
ADHD / ADD*

YesNo
Anemia*

YesNo
Allergies*

YesNo
Asthma / Breathing Issues*

YesNo
Autism Spectrum*

YesNo
Bleeding Disorder*

YesNo
Brain Injury*

YesNo
Cancer / Malignancy*

YesNo
Cardiac Disease / Murmur*

YesNo
Cerebral Palsy*

YesNo
Chemo / Radiation*

YesNo
Cystic Fibrosis*

YesNo
Delayed Development*

YesNo
Depression / Anxiety*

YesNo
Diabetes*

YesNo
Down's Syndrome*

YesNo
Earaches / Infections*

YesNo
Emotional / School Issues*

YesNo
Epilepsy / Seizure*

YesNo
Hearing Impairment*

YesNo
Hepatitis*

YesNo
Immune Disorder*

YesNo
Kidney / Liver Issues*

YesNo
Muscular Disorder*

YesNo
Premature Birth*

YesNo
Rheumatic Fever*

YesNo
Speech Disorder*

YesNo
Tuberculosis*

YesNo
Visual Impairment*

YesNo
Does Your Child Have any Disease, Condition, or Problem Not Listed?*

YesNo
If so, what?
Have YOU or YOUR CHILD had a COUGH, FEVER, RECENT Loss of TASTE or SMELL, SORE THROAT, or SHORTNESS OF BREATH in the last 48 hours?*

Yes - Please do not enter the buildingNo
Have YOU or YOUR CHILD TESTED POSITIVE or been DIAGNOSED as having COVID-19, or had CONTACT with a person infected with COVID-19 within the last 14 days?*

Yes - Please do not enter the buildingNo
Do you have any concerns regarding your child's dental health?*

YesNo
If so, what?
Do you consent to diagnostic dental X-rays on your child today, if requested by the Doctor?*

YesNo
To the best of my knowledge, all of the preceding answers are true and correct. If there is ever any change in my child’s health or if my child’s medicines change, I will inform the doctor of dentistry at the next appointment without fail.

I hereby acknowledge and understand that there may be an increased risk that COVID-19 may be transmitted in any place of public accommodation, which includes my dentist’s office. I have been informed by my dentist of their desire to protect their patients, staff, and the community at large.

I agree to notify the dental practice if within 14 days I or my child becomes ill with COVID-19 symptoms or test positive for COVID-19. I understand the dental practice has a legal and ethical obligation to inform me if a staff person I had contact with tested positive for COVID-19 within 14 days.
Signature

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Printed Name*
Relationship to Patient*
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Patient Medical History Form

Has Your Child Had a History Of: