Health History

PATIENT INFORMATION

DENTAL HISTORY

MEDICAL HISTORY

Any history of cerebral palsy, seizures, fainting, or loss of consciousness?
Any sensory disorders? (seeing, hearing, Sensory Integration Disorder)

Has your child been diagnosed with PDD, autism, ADHD or ADD?

Any history of congenial heart disease, heart murmur or rheumatic fever?

Has any heart surgery been done or recommended?

Has your child ever had a blood transfusion?

Any history of anemia or sickle cell disease?

Does your child bruise easily or bleed excessively from small cuts?

Any history of pneumonia, cystic fibrosis, asthma, or difficulty breathing?

Any history of stomach, intestinal, kidney or liver problems?

Any history of hepatitis?

Any history of diabetes?

Any history of thyroid disease or other glandular disorders?

Has your child ever been hospitalized?

(If yes, please explain)

Is your child up to date with immunizations? (DPT, IPV,MMR, HIB, HepB)

Any additional related problems?