Patient Name:
Email:

MEDICAL HISTORY

Child's Physician/Pediatrician:
Phone Number:
Mailing address:
City:
State:
Zip code:
Is your child in good health?
Date of last physical exam:
If no, please explain:
Are your child's immunizations current?
If no, list reason:
Is your child currently taking any prescription medications?
If yes, please give name, reason & date started:
Is your child currently taking any over the counter medications?
If yes, please give name, reason & date started:
Is your child currently taking any vitamins or dietary supplements?
If yes, please give name, reason & date started:
Has your child ever been hospitalized, had surgery and/or general anesthesia?
If yes, please list date and explain:
Has your child ever been treated in an emergency room?
If yes, please list date and explain:
Please indicate if your child has been diagnosed and/or treated for any of the following – if No, please select N for each:
Acid Reflux
ADHD
AIDS
Anemia
Arthritis Rheumatism
Artificial Heart Valves
Artificial Joints
Aperger's Syndrome
Asthma
Autism
Back Problems
Bleeding Abnormally
Extractions or Surgery
Blind
Blood disease
Cancer
Cerebral Palsy
Chemical dependency
Chemotherapy
Congenital Heart Lesions
Cortisone Treatments
Cough-persistent / bloody
Developmental Disorder
Diabetes
Down's Syndrome
Epilepsy
Fainting or Dizziness
Glaucoma
Headaches
Hearing Impaired
Heart Murmur
Heart Problems
Hepatitis
Type
Herpes
High Blood Pressure
HIV Positive
Jaundice
Kidney Disease
Liver Disease
Low Blood Pressure
Mental Disorder
Mitral Valve Prolapse
Nervous Problems
Pervasive Developmental Disorder (PDD)
Psychiatric Care
Radiation Treatment
Respiratory Disease
Rheumatic Fever
Scarlet Fever
Scoliosis
Seizures
Shortness of Breath
Sickle Cell Anemia
Sinus Trouble
Skin Trouble
Spinal Bifida
Stroke
Swollen Neck Glands
Thyroid Problems
Tonsillitis
Tourette's Syndrome
Tuberculosis
Tumor or growth on Head/Neck
Other
Has your child ever had any serious illness not listed above?
If yes, please explain:
Please list all known allergies for your child:
Food Allergies (List)
Other (List):
Does your child have any handicaps or disabilities?
If yes, please explain:
Has your child ever been evaluated by a specialist? If yes, please list:
Name:
Specialty:
Phone:
Name:
Specialty:
Phone:
Is there any other significant medical history pertaining to your child or his/her family that the dentist should be told?
If yes, describe:

I affirm that the information above is correct to the best of my knowledge. I understand that providing incorrect information can be dangerous to my child’s health and it is my responsibility to inform the licensed professionals and staff of Dr. Jeannette M. Pope‐Ozimba’s Pediatric Dental Office of any changes in my child’s medical status.

Legal Guardian Signature:

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Legal Guardian Name (PRINT)
Date