Patient Health History - Child Patient Health HistoryName First Last Birth datePhone (Home)Phone (Work)For the following questions, please select yes or no, whichever applies1. Are you in good health?YesNo2. Has there been any change in your general health in the past year?YesNo3. Are you currently under the care of a physician?YesNoIf so, for what condition(s)?4. Have you had any serious illness, operation, or been hospitalized in the past 5 years?YesNo5. Do you have or have you had any of the following diseases of problems (please check ones that apply)?YesNoA. Rheumatic Fever, Rheumatic Heart Disease, Artificial Heart Valves?YesNoB. Congenital Heart Lesions, Heart Murmur, Mitral Valve Prolapse?YesNoC. Cardiovascular Disease (heart trouble, heart attack, angina, coronary insufficiency, coronary occlusion, high blood pressure, arteriosclerosis, stroke?YesNoi. Chest pain upon exertion?YesNoii. Are you ever short of breath after mild exercise or when lying down?YesNoiii. Do your ankles swell?YesNoiv. Do you have a pacemaker?YesNoD. Tuberculosis?YesNoE. Persistent cough or cough that produces blood?YesNoF. Respiratory problems, emphysema, bronchitis?YesNoG. Asthma, hay fever, sinus trouble?YesNoH. Fainting spells or seizures?YesNoI. Diabetes?YesNoJ. Hepatitis, Jaundice, or Liver Disease?YesNoK. Aids or HIV Infection?YesNoL. Sexually Transmitted Disease?YesNoM. Thyroid problems?YesNoN. Arthritis, Inflammatory Rheumatism (painful swollen joints)?YesNoO. Stomach problems?YesNoP. Kidney Trouble?YesNoQ. Low blood pressure?YesNoR. Epilepsy?YesNoS. Psychological disorders?YesNoT. Cancer?YesNoU. Join replacement (pins, plates or posts)?YesNo6. Have you had abnormal bleeding associated with previous extractions, surgery or trauma?YesNoA. Have you ever required a blood transfusion?YesNo7. Do you have any blood disorders such as anemia?YesNo8. Have you had surgery or x-ray treatment for a tumor, growth, or other condition of the head or neck?YesNo9. Are you taking any of the following drugs or medications?A. Antibiotics (penicillin, erythromycin, sulfa drugs)?YesNoB. Antihistamines/Allergy Drugs?YesNoC. Aspirin?YesNoD. Tranquilizers?YesNoE. Insulin?YesNoF. Cortisone/Steroids?YesNoG. Heart Medicine?YesNoH. Blood Thinners/Anticoagulants?YesNoI. Blood Pressure Medication/Nitroglycerin?YesNoJ. Others?YesNo10. Are you allergic or have you reacted to adversely to:A. Local Anesthetics (e.g. novocaine, carbocaine)?YesNoB. Penicillin or other antibiotics?YesNoC. Sulfa drugs?YesNoD. Barbiturates?YesNoE. Aspirin?YesNoF. Codeine or other narcotics?YesNoG. Others?YesNo11. Do you use tobacco in any form?YesNoIf so, what type(s)YesNo12. Do you have any disease, condition or problem not listed above that you think we should know about?YesNoIf so, please describeWomenAre you pregnant?YesNoDo you have any problems with your menstrual period?YesNoAre you nursing?YesNoAre you taking birth control pills?YesNoPhysician NamePhysician Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Physician PhoneI certify that I have read and understand the above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of the staff, responsible for any errors or omission that I may have made in the completion of this form.Agree to terms?Yes, I agree.No, I disagree.Electronic Signature (E-Signature) AgreementBy selecting the "I Accept" button, you are signing this Release of Records electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Release of Records. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature. You also represent that you are authorized to sign this Release of Records for all persons listed on this form.*I AcceptElectronic Signature:Name* First Last Today's Date* Date Format: MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.