MEDICAL HISTORY UPDATE

All questions contained in this questionnaire are strictly confidential and will become part of the patient’s record.
A Medical History Update must be provided at every dental visit.


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Patient’s Primary Address: City: State: Zip:
Who does the patient live with?:      Both Parents       Mother      Father      Other: 
Parent’s/Guardian’s First Name: Last Name:
Home Number: Cell/Mobile Number:
Which number would you like to have appointments confirmed?   HOME     CELL/MOBILE
E-mail Address:
Who is accompanying the child today or is expected to on the date of their appointment?
First Name: Last Name: Relation: Biological Adopted Foster Nanny Other:
Is your child a ward of the state? Yes No If yes, case worker's contact number:

 
  Patient’s First Name:
Patient’s First Name:
Patient’s First Name:
Patient’s First Name:
  Last Name:
Last Name:
Last Name:
Last Name:
  Date of Birth: Date of Birth: Date of Birth: Date of Birth:

 CONDITIONS

       
Does the patient have any MEDICAL CONDITIONS?
(For example: ADHD, Asthma, Autism, Cerebral Palsy,Diabetes, Epilepsy,
Seasonal Allergies, etc)
  Yes     No   Yes     No   Yes     No   Yes     No
If YES, what conditions?
Does the patient have any HEART conditions?
(For example: Heart Murmur, Congenital Heart Defect, etc)
  Yes     No   Yes     No   Yes     No   Yes     No
If YES, what conditions?
Does the patient require an ANTIBIOTIC before being seen?   Yes     No   Yes     No   Yes     No   Yes     No
If YES, did the patient take the antibiotic?   Yes     No   Yes     No   Yes     No   Yes     No
Is your child followed by a specialist?   Yes     No   Yes     No   Yes     No   Yes     No
If yes, please provide name and contact information:

 ALLERGIES

       
Does the patient have an ALLERGY to LATEX?   Yes     No   Yes     No   Yes     No   Yes     No
Does the patient have any OTHER ALLERGIES?
(For example: Animals, Foods, Medications, Nickel, etc)
  Yes     No   Yes     No   Yes     No   Yes     No
If YES, what allergies?

 MEDICATIONS

       
Is the patient currently taking ANY medications/vitamins?   Yes     No   Yes     No   Yes     No   Yes     No
If YES, what medications/vitamins?
Why is the patient taking this medication (i.e., what condition is it for)?

 DENTAL CONCERNS

       
Do you (or the patient) have any DENTAL CONCERNS?   Yes     No   Yes     No   Yes     No   Yes     No
If YES, what concerns do you have?

 CONSENT FOR TODAY

       
X-Rays (if needed): Essential for diagnosing tooth decay and other abnormalities   Yes     No   Yes     No   Yes     No   Yes     No
Fluoride Application: To help fight tooth decay and strengthen developing teeth   Yes     No   Yes     No   Yes     No   Yes     No
 
INDICATE CHANGES TO THE FOLLOWING (CHECK ALL THAT APPLY):
  MARITAL STATUS       INSURANCE       ADDRESS/PHONE/E-MAIL       PRIMARY GUARDIANSHIP       MEDICATIONS
 


I certify that the information I have given is correct to the best of my knowledge.  It will be held in confidence and it is my responsibility to inform this office of changes in the patient’s medical status.  I authorize the dental staff to perform all necessary dental treatment the patient may need.  I authorize the release of all information necessary to secure benefits otherwise payable to me.  I assign directly Fishers Pediatric Dentistry all insurance payments otherwise payable to me.  I understand that I am responsible for the full balance of the account regardless of my dental benefits.  In case of default, I agree to pay all reasonable costs and fees associated with the collection of the account balance, including but not limited to third party collection fees, court filing fees and attorney fees. 

I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction.  I will not hold the dentist or any member of the staff responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.  I affirm that my signature represents my agreement to all the above mentioned terms.

 
Signature Date