MEDICAL HISTORY UPDATE
To assist us in keeping your child’s medical history up to date, please review the following questions and note any changes.
Patient First Name
Patient Last Name
Date of Birth
Age
Has any of the following CHANGED since your last visit to our office?
PARENT/ GUARDIAN’S NAME?
Yes
No
If yes, note changes here:
RESIDENCE/ MAILING ADDRESS?
Yes
No
If yes, note changes here:
HOME OR EMERGENCY PHONE NUMBER?
Yes
No
If yes, note changes here:
HAS YOUR CHILD’S MEDICAL HISTORY CHANGED?
Yes
No
If yes, note changes here:
IS YOUR CHILD CURRENTLY TAKING ANY MEDICATIONS?
Yes
No
If yes, note changes here:
DOES YOUR CHILD HAVE ANY ALLERGIES?
Yes
No
If yes, note changes here:
ANY INJURY TO THE FACE, HEAD OR NECK SINCE THE LAST VISIT?
Yes
No
If yes, note changes here:
ANY DENTAL PROBLEMS THAT YOU ARE AWARE OF?
Yes
No
If yes, note changes here:
OTHER DENTAL/ MEDICAL RELATED CONCERNS?
Yes
No
If yes, note changes here:
HAS THERE BEEN A CHANGE IN DENTAL INSURANCE?
Yes
No
If yes, note changes here:
HAS THERE BEEN A CHANGE IN YOUR CHILD’S PHYSICIAN?
Yes
No
If yes, note changes here:
HAS YOUR CHILD SEEN A PHYSICIAN SINCE THE LAST VISIT?
Yes
No
If so, why?
Relationship to Patient
Print First Name
Print Last Name
Signature
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Clear
Please sign the document
Date
Signature of Patient, Parent or Guardian:
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Online Signature
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Draw your signature inside the box
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