Health History Update Child's Name(Required)Date(Required)Father's Full Name(Required)Mother's Full Name(Required)Home Phone Number(Required)Work Phone Number(Required)Cell Phone Number(Required)Okay to Text?(Required) Yes No Address(Required)Email address for confirmations(Required)1. Is there anything about your child's teeth, mouth, or jaw that concerns you?(Required) Yes No Do you have any concerns about today’s appointment that you’d like brought to your doctor’s attention?2. Is your child presently under the care of a physician for any medical reasons?(Required) Yes No 3. Is your child taking any medications?(Required) Yes No 4. Does your child have a medical condition? (heart murmur, heart defect, etc.) that requires antibiotics before dental treatment?(Required) Yes No If so, has your child taken the prescribed medication? What medication?Dosage?When?5. Is your child allergic to a medicine or other product?(Required) Yes No 6. Is your child allergic to vinyl, metals or other product?(Required) Yes No 7. Is your child allergic to latex (balloons or other products)?(Required) Yes No Are you on well water?(Required)Do you use bottled water?(Required) Yes No Are you interested in information on athletic mouth guards?(Required)Name of parent or guardian(Required)
