Child medical history Form

Child medical History

Current physical health is :
Are you currently under the care of a physician?(Required)
Is your child allergic to any of the following?

Has the child experienced any of the following?

Acid Reflux
Diabetes
Heart Murmur
Snoring
Asthma
Dizziness
Hearing Impaired
HIV/AIDS
Congenital Heart Defect
Eyesight Issues
Learning/Behavior Issues
Hepatitis
Depression/Anxiety
Headaches
Seizures
Premed Required

Dental History

Has your child ever had any of the following:

Injuries to mouth/teeth
Sealants Placed
Baby teeth removed
History of Cavities
Issues with past dental treatment
Nitrous Oxide

Does your child

Eats Candy
Chews Gum
Drinks Soda
When does your child brush his/her teeth?
Does your child floss?
How does your child receive fluoride?
Consent(Required)
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