• PATIENT MEDICAL HISTORY

    PATIENT MEDICAL HISTORY

    (v 1/15/2021)

  • Please complete one medical history for each patient. If you do not know the answers or feel uncomfortable with the question, please do not answer. 

  • Patient Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Your relationship to the patient*
  • Does the patient have any medication or food allergies?*
  • Does the patient take any medications (including vitamins) regularly?*

  • Birth History

  • Do you know the patient's birth history?*

  • Past Medical History

  • Are immunizations up to date?*
  • Has there been any developmental concerns with the patient?*
  • Does the patient have any known medical problems?*
  • Has the patient ever been hospitalized*
  • Has the patient had any surgeries?*

  • Family / Social History

  • Do you know the patient's family history?*
  • Parents are (check all that apply)*
  • Anyone at home smoke?*
  • Any firearms in the home?*
  • Are firearms stored unloaded and in a safe?
  • Which does the patient attend?*
  • Does the patient see a dentist regularly?*
  • Do you fear for the patient's or your safety at home?*
  • Today's Date
     / /
    2 digit month, 2 digit day, 4 digit year

  • Thank you for taking the time to answer the questions.

  • Should be Empty: