Health History UpdateChild’s Name* Date* MM slash DD slash YYYY Father’s Full Name* Mother’s Full Name* Home Ph #* Work Ph #* Cell Ph #* Ok to text?* Yes No Address* Email address for confirmations* 1.) Is there anything about your child’s teeth, mouth or jaw that concerns you?* 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?* Yes No If so, for what?* 3.) Is your child taking any medications?* Yes No If Yes, what medicines?* 4.) Does your child have a medical condition? (heart murmur, heart defect, etc.) that requires antibiotics before dental treatment?* Yes No If Yes, what medical condition?* If so, has your child taken the prescribed medication?What? Dosage? When? 5.) Is your child allergic to a medicine or other product?* Yes No Allergic to What medicine?* 6.) Is your child allergic to vinyl, metals or other product?* Yes No Allergic to What metal or other product?* 7.) Is your child allergic to latex (balloons or other products)?* Yes No Allergic to balloons or other product?* 8.) Are you on well water?* Do you use bottled water?* Yes No What Brand?* 9.) Are you interested in information on athletic mouth guards?* Name of parent or guardian* PhoneThis field is for validation purposes and should be left unchanged.
