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Home / Medical History Update Form




PLEASE CHOOSE OFFICE LOCATION

LOS GATOS        WILLOW GLEN 

CHILD’S NAME: AGE:
Is your child in Good Health? YesNo
Is your child currently under treament by physician for any reason? YesNo
Is your child receiving any medications or drugs? YesNo If yes, which
To your knowledge, is your child sensitive or allergic to anything, including medications, nuts, or latex? YesNo 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? YesNo
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: