Medical-Dental History Page 2
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1
2
3Medical History
1) Is your child under the care of a physician at present?
YES
NO
If yes, since when and why?
________________________________________________________________________________________________________
3) Has your child ever had a serious illness or been hospitalized? YES
NO
If yes, please
Explain:_____________________________________________________________________________________________________
4) Is your child receiving medication?
YES
NO
Please list the medication:__________________________________________________________________________________________________
5) Is your child allergic to any medication, drugs, or had a bad reaction to any drug, medicine, or food? YES
NO
If yes, please list:_____________________________________________________________________________________
6) Does your child have any limitations to physical activities?
YES
NO
If yes, please explain:
____________________________________________________________________________________________________________
7) Does your child have problems: (please circle)
Concentrating
Cooperating
Learning
Understanding
None of These
8) Are your child’s immunizations up to date?
YES
NO
10) Does your child have acquired immune deficiency / HIV?
YES
NO
13) Have you ever been told that your child has/ or has received treatment for any of the following conditions?
(please circle any that apply)
Allergy
Anemia
Arthritis
Asthma
Autism
Birth Defects
Bleeding
Blood Transfusions Brain Injury
Cancer
Cerebral Palsy
Chicken Pox
Child Abuse
Cleft Lip/Palate
Developmental Delay
Diabetes
Emotional Disorders
Epilepsy
Eyesight Problems Fainting
Headaches
Hearing Loss
Heart Trouble
Hemophilia
Hepatitis
High Blood Pressure Hyperactive
Kidney Problems
Latex Allergy
Leukemia
Liver Problems
Lung Problem
Malignant Hyperthermia Mentally Challenged Muscular Dystrophy
Nutritional Deficiency
Pneumonia
Psychiatric Care
Scarlet Fever
Seizures
Speech Problems
Tuberculosis
14) Other:_____________________________________________________________________________________________
Parent’s Signature:________________________________
Date:_______________________
Dentist’s Signature: _______________________________
Date: _______________________
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