Pediatric Health History Form Page 2
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1
2ALLERGIES:
YES NO
Does the patient have allergies or develop a reaction to medications, foods, or environmental allergens? If yes, please specify:
Allergic To: 1) ______________________________
Reaction: 1) ___________________________________
Allergic To: 2) ______________________________
Reaction: 2) ___________________________________
Allergic To: 3) ______________________________
Reaction: 3) ___________________________________
MEDICATIONS, VITAMINS, DIET SUPPLEMENTS, OR NATURAL/HERBAL PRODUCTS:
YES NO
Does the patient take medications, diet supplements, vitamins, or natural or herbal products?
Medications, Vitamins, Diet Supplements, or Natural/Herbal Products
How Much / When
TOBACCO AND RECREATIONAL DRUG USE:
YES NO
Does the patient use or has used tobacco (smoking, snuff, chew, bidis)?
YES NO
Does the patient use or has the patient used prescription or street drugs or other substances for recreational purposes?
To the best of my knowledge, the answers I have given are accurate. I agree to report changes in the patient’s medical status to the dentist, I give the
dentist permission to obtain additional information about the patient’s medical history from the patient’s physician as is needed to provide dental
treatment.
Person Completing this Form: Signature: _______________________________Relationship to Patient:______________ Date: _______________
YES NO Interpreter/Translator Name: Print Name:_____________________________Signature: ______________________________
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