Child medical history Form

Child medical History

"*" indicates required fields

Current physical health is :
Are you currently under the care of a physician?*
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*
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