Health History Update Health History Update Child’s Name Child's Name First First Middle Middle Last Last Goes By Nickname Date of Birth * Age Gender Male Female Medicaid or Texas CHIP * Yes No Medicaid / ID Number Home Address * Home Address Home Address Home Address City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Reason for today’s visit (check all that apply) Check-up Cavity Pain Accident OtherOther Name of person who is accompanying your child today? * Relationship to child * Does this person have legal custody of this child? * Yes No Email of a legal guardian * Medical History Update Any changes in medical history or illnesses? * No Yes (please explain)Yes (please explain) List current medications (including herbal) Is there any allergy to penicillin or other drugs? * No Yes (please list)Yes (please list) Are there any other allergies? * No Latex Metal Food Pollen Dust Dye Other:Other: Do you have any dental concerns? * No YesYes Would you be interested in discussing straightening your teeth with clear aligners (Invisalign) today? * No Yes *Note: this would not be covered by your insurance* Has this child had any treatment on any of the following? Blood/ Circulatory No Yes Gastrointestinal (stomach) No Yes Muscles No Yes Endocrine glands No Yes Kidney / Bladder No Yes Nervous System No Yes Eyes, Ears, Nose, Throat No Yes Liver No Yes Skin No Yes Has this child ever been diagnosed as having any of the following conditions? ADD / ADHD No Yes Emotional Disorder No Yes Pneumonia No Yes AIDS / HIV No Yes Epilepsy / Seizures No Yes Pregnancy No Yes Anemia No Yes Eye Problems No Yes Rheumatic Fever No Yes Allergy No Yes Excessive Bleeding Problem No Yes Scarlet Fever No Yes Arthritis No Yes Fainting No Yes Scoliosis No Yes Asthma No Yes Hearing Loss No Yes Sickle Cell Anemia No Yes Autism Spectrum Disorder No Yes Heart Disease / Heart Murmur No Yes Sinus Problems No Yes Brain Injury No Yes Hemophilia No Yes Sleep Apnea No Yes Bronchitis No Yes Hepatitis No Yes Snoring at Night No Yes Type of Hepatitis * Cancer No Yes Sore Throats (Frequent) No Yes Jaundice No Yes Cerebral Palsy No Yes Leukemia No Yes Spina Bifida No Yes Chicken Pox No Yes Measles No Yes Syndrome No Yes Explain * Cleft Lip / Cleft Palate No Yes MRSA No Yes Tetanus No Yes Congenital Birth Defect No Yes Mumps No Yes Tuberculosis No Yes Developmentally Delayed No Yes Mouth Breathing No Yes Venereal Disease No Yes Diabetes No Yes Nutritional Deficiency No Yes Whooping Cough No Yes Type of Diabetes * Drug, Alcohol, Tobacco Use No Yes Orthopedic Problems No Yes Other Services my child is scheduled to receive today: * Routine dental check-up Emergency evaluation Follow-up (for recent treatment / surgery) Dental treatment (fillings, crowns, sealants, extractions, etc) I give my consent for my child to have a * dental exam teeth cleaning fluoride treatment x-rays (A separate consent form is required for fillings, crowns, sealants, extractions, etc) The information I have given is correct to the best of my knowledge and I understand that it will be held in the strictest confidence. I understand that providing incorrect information can be dangerous to my child’s health. I understand it is my responsibility to inform this office of any changes in my child’s medical status. * I authorize the release of information to all of my insurance companies. I understand that I am responsible for all financial responsibilities. * Your name * Relationship to patient * Your email * Signature * Clear If you are human, leave this field blank. Submit Δ
