Health History Information
Please fill out this form for each child individually
Patient Name:
Pediatrician/Primary Care Physician:
Current Medications:
None
Please CHECK all that apply:
Allergies:
Medication:
Food:
Latex
NONE
Other
List Medication
List Food
Respiratory:
Asthma
TB(Tuberculosis)
Cystic Fibrosis
Bronchitis
NONE
Other
Ear/Nose/Throat:
Large Tonsils
Sleep apnea with nighty snoring
Narrow Airway
Difficulty Swallowing
Seasonal Allergies
Sinus Infection
NONE
Other
Cardiac:
Congenital Abnormality:
Heart Condition:
High Blood Pressure
Valve Dysfunction:
Other
Describe Congenital Abnormality
Describe Valve Dysfunction
Describe Heat Condition
Hematology/Oncology/Other:
Anemia(requiring treatment)
Bleeding Disorder:
MRSA or other infectious disease
Sickle Cell Disease
Cancer:
HIV/AIDS
NONE
Other
Describe Bleeding Disorder
Describe Cancer
GI/GU:
GERD/acid reflux
Hiatal hernia
Abdominal Pain:
Hepatitis/Liver transplant
NONE
Other
Describe Abdominal Pain
Endocrine/Metabolic:
Diabetes- Type 1/ Type 2
Hypothyroid/Hyperthyroid
Kidney Transplant
Metabolic Syndrome
NONE
Other
Neurological/Musculoskeletal:
Seizures/ Epilepsy
Cerebral Palsy
Muscular Dystrophy
Low muscle ton/Paralysis
Arthritis
Headaches
Neuromuscular Disease
NONE
Other
Psychosocial/Social:
Development Delay:
Growth Concerns:
ADD/ADHD
Autism
NONE
Other
Describe Development Delay
Describe Growth Concerns
If the patient is under 12 months of age, did they receive the Vitamin K shot at birth?
Yes
No
Are there any medical conditions not listed above that you feel we should be aware of?
Yes
No
If yes, please explain:
Dental / Orthodontic Information
Does the patient see another dentist for routine care?
Yes
No
If yes, who?
Has the patient had a professional dental cleaning in the last 6 months?
Yes
No
What are the main dental / orthodontic concern(s) you would like to address?
Signature:
Clear
Date:
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Month
-
Day
Year
Date
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