Fill Out the Medical History Form Prior to Your Visit : Port Pediatric Dentistry

Child's Name:
Is your child under the care of a physician for anything other than well child check ups?	Yes No
If yes, since when and why?
Is your child allergic to anything?	Yes No
List:
Is your child taking any medications including over the counter medications?	Yes No
Please give medication, dose and reason:
Are your child's immunizations current?	Yes No
Have you ever been told that your child needs to take an antibiotic before having dental treatment?	Yes No
Has your child had any serious illness?	Yes No
Has your child ever been hospitalized or an emergency room visit?	Yes No
If yes please explain:
Were there any difficulties with birth?	Yes No
Do you consider your child to be:	Advanced in the learning process Progressing normally Slower in the learning process
Please check if your child has a history of or has been treated for any of the following:
Heart disease Heart murmur Bleeding/transfusions Asthma Anemia Blood dyscrasias Tonsil/adenoid problems TB Liver/GI disease Sickle cell disease Diabetes HIV/AIDS Kidney disease Rheumatic fever Hepatitis Mental delay Seizures Cleft/Lip palate Speech/hearing problems Autism Cerebral Palsy Endocrine disorder Congenital birth defects Cancer Physical delay Vision problems Adverse drug reaction ADD/ADHD Recurrent headache Frequent infections Emotional problems Arthritis Spina bifida Snoring Abuse Other