3299 Clear Vista CT NE STE B,
Grand Rapids,
MI
49525
(616) 608-6826
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Medical History Form
Child's Full Name
Is your child under the care of a physician for anything other than well child check up?
Yes
No
If yes, since when and why?
Is your child allergic to anything
Yes
No
List:
Is your child taking any medication including over the counter medications?
Yes
No
Please list 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 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 at birth?
Yes
No
If yes please explain:
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
LiverGI 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
Any history of malignant hyperthermia in your family and/or your child?
Yes
No
Does your child have von Willebrand disease?
Yes
No
Any family history of problems with general anesthesia?
Yes
No
If yes please explain:
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Hamilton Pediatric Dentistry P.C. - Veronica Hamilton, DDS
3299 Clear Vista CT NE STE B
Grand Rapids
MI
49525
Phone:
(616) 608-6826
