Dr. Rabitz Pediatric Dentistry-Medical History Update

Medical History Update Patient Details

First Name*

Last Name*

Date Of Birth*

Medical History Update Contact Info

Email*

Home Phone Number

Cell Phone Number*

Work Phone Number

Work Extension Number

Medical History Update Medical History Update

IS YOUR CHILD:

In Good Health?*

Yes
No

Currently under treatment by physician or recently hospitalized for any reason?*

Yes
No

Explain

Receiving any medications or drugs?*

Yes
No

Explain

Allergic to latex?

Yes
No

List any known allergies or sensitivities (i.e. metal, acrylics, or dye)

Has your child had any history of:

AIDS*

Yes
No

Anemia*

Yes
No

Asthma*

Yes
No

Birth Disease*

Yes
No

Bladder Disease*

Yes
No

Blood Disease*

Yes
No

Blood Transfusion*

Yes
No

Bronchitis*

Yes
No

Cerebral Palsy*

Yes
No

Chicken Pox*

Yes
No

Convulsions*

Yes
No

Diabetes*

Yes
No

Drug Problems*

Yes
No

Epilepsy*

Yes
No

Fainting*

Yes
No

Hearing Problems*

Yes
No

Heart Disease*

Yes
No

Hemophilia*

Yes
No

Hepatitis in Family*

Yes
No

HIV-Positive*

Yes
No

Kidney Disease*

Yes
No

Liver Disease*

Yes
No

Malignancies*

Yes
No

Measles*

Yes
No

Mononucleosis*

Yes
No

Mumps*

Yes
No

Psychiatric Treatment*

Yes
No

Rheumatic Fever*

Yes
No

Scarlet Fever*

Yes
No

Sinus Infection*

Yes
No

Thyroid*

Yes
No

Tuberculosis*

Yes
No

Other

Yes
No

If yes to any of the above questions, please explain

Has your child had any unfavorable experience with previous medical or dental care?*

Yes
No

If yes, explain

Name or Child's Physician if changed

Phone

Parent/Guardian Name

SIGNATURE (Signature)*

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Medical History Update Patient Details

Medical History Update Contact Info

Medical History Update Medical History Update

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