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Home / 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:
Dr. Rabitz. All rights reserved.