Pediatric First Visit Medical/dental History Form Page 3

*including juice, flavored drinks, sodas, carbonated drinks, energy drinks, sports drinks, sweetened beverages

Please list all medicines and supplements that your child is currently taking:

Date

Medicine or

Medical

Notes

Date

Dose

Discontinued

Supplement

Condition

(for office use)

No persons outside of this office will be provided this information unless properly authorized by you or required by law. By signing below, you

agree that the information given is accurate to your knowledge and that you will notify us of any changes at subsequent appointments.

Signature: _______________________________________________

Date:______________________

Relationship to patient:____________________________________

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Parent category: Medical