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*EmailThis field is for validation purposes and should be left unchanged.
