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Medical History Update Form
CHILD’S NAME:
AGE:
Is your child in Good Health?
Yes
No
Is your child currently under treament by physician for any reason?
Yes
No
Is your child receiving any medications or drugs?
Yes
No
If yes, which
To your knowledge, is your child sensitive or allergic to anything?
Yes
No
If yes, what
HAS YOUR CHILD HAD ANY HISTORY OF: If Yes, please explain under “Remarks”
AIDS
Cerebral Palsy
Heart Disease
Mononucleosis
Anemia
Chicken Pox
Hemophilia
Mumps
Asthma
Convulsions
Hepatitis in Family
Psychiatric Treatment
Birth Disease
Diabetes
HIV-Positive
Rheumatic Fever
Bladder Disease
Drug Problems
Kidney Disease
Scarlet Fever
Blood Disease
Epilepsy
Liver Disease
Sinus Infection
Blood Transfusion
Fainting
Malignancies
Thyroid
Bronchitis
Hearing Problems
Measles
Tuberculosis
Other
(please explain):
Has your child had any unfavorable experience with previous medical or dental care?
Yes
No
Remarks:
FOR INSURANCE PURPOSES:
Mother’s Name:
Birthdate:
Father’s Name:
Birthdate:
NEW Address/Phone
NEW Insurance Company /Group#,if any
Signature:
Date:
Name of child’s physician:
Phone:
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