If you are an existing patient please fill out the following form. All new patients must fill out the new patient form on the previous page. The information provided on this form is important to your child's dental health and must be filled out by a parent or legal guardian.

Medical History Update Form

(Please complete this form for returning patients)

Today's Date

YYYY

Child's Name

First Name

Last Name

Age

Weight

Child's favorite movie

We would like to have it playing for them!

Parent's Name

First Name

Last Name

Relationship to child

Please provide us with any changes to your contact information since last visit:

Address, Phone Number, E-mail

Please provide us with any changes to your dental insurance:

Name of Pediatrician

Please list any medications (prescriptions, vitamins or supplements)

Please list any allergies

Please list any hospitalizations, surgeries or other significant injury/illness

Any changes to your child's health since last visit?

Any particular concerns for your child's teeth?

Has your child had any trauma to the mouth, teeth or jaws since last visit?

Does your child have any habits?

None

Pacifier

Thumb or finger sucking

Grinding/Clenching

Mouth breathing

Other

Is there anything else we should know before treating your child?