Medical History Form

Location*

Patient Name*

Date of Birth*

Emergency Contact (Contacto De Emergencia)

Patient Medical History (Historia Medica Del Paciente)

Family Physician’s Name and Address (Nombre de los Medicos Familiares y Direccion)

Phone (Telefono)

List any specialists your child sees, outside of your family physician, and their information (Liste a cualquier especialista que ve su hijo, fuera de su medico familiar y su informacion)

List any medications, prescription or over the counter, your child is taking and why (Liste cualquier medicina, prescripcion o sobre el contador, su hijo esta tomando y por que)

List any hospitalizations or surgeries your child has endured, when and why (Liste cualquier hospitalizacion o cirugia que su hijo ha permitido, cuando y por que)

Does your child have any emotional, intellectual, nervous, or behavioral disorders, explain (Tiene su hijo algunos trastornos emocionales, intelectuales, nerviosos o de conducta, explicar)

COVID-19

Has your child or anyone in your household been exposed to anyone who has tested positive for, or is suspected to have, COVID‐19?

Yes
No

Has your child or their accompanying guardian traveled internationally in the last 14 days?

Yes
No

Does your child or their accompanying guardian currently have (or have they had in the last three days) a fever of 100.4 or higher or are they exhibiting symptoms of respiratory illness?

Yes
No

Is your child allergic to any of the following (Es su hijo alergico a alguno de los siguientes)

Antibiotics (Antibioticos)

Yes
No

If yes

Other drugs (Otras drogas)

Yes
No

If yes

Nuts (Nueces)

Yes
No

If yes

Other food or fruit (Otros almentos o frutos)

Yes
No

If yes

Seasonal/environmental (Ambiental/estacional)

Yes
No

If yes

Gluten

Yes
No

Red dye (Tinte rojo)

Yes
No

Latex

Yes
No

Has your child been diagnosed with any of the following conditions (Su hijo ha sido diagnoseado con cualquierda de las siguientes condiciones)

ADD/ADHD (TDA/TDAH)

Yes
No

Anemia/Sickle Cell Anemia (Celula Falciforme)

Yes
No

Asthma/Reactive Airway (Asma/Via Aerea Reactiva)

Yes
No

Autism (Autismo)

Yes
No

Bleeding/Blood Disorder (Trastrono De Sangre)

Yes
No

Cancer/Leukemia/Malignancies (Leucemia)

Yes
No

Cerebral Palsy (Paralisis Cerebral)

Yes
No

Cleft Lip/Palate (Labio Leporino/Paladar)

Yes
No

Diabetes Type 1 (Tipo De Diabetes 1)

Yes
No

Diabetes Type 2 (Tipo De Diabetes 2)

Yes
No

Endocrine Disorder (Desorden Endocrino)

Yes
No

Fainting Spells/Dizziness (Desmayos/Mareo)

Yes
No

Heart Condition (Problemas Cardiacos)

Yes
No

Hepatitis

Yes
No

H.I.V. (SIDA)

Yes
No

Liver Disease/Condition (Enfermedad Del Higado)

Yes
No

Positive TB Test (Prueba De TB Positiva)

Yes
No

Pregnancy (Embarazada)

Yes
No

Seizures/Epilepsy (Embargos/Epilepsia)

Yes
No

Stomach/Intestinal Disorder (Trastorno Estomago)

Yes
No

Other (Otra)

Yes
No

If yes

Please check whether your child receives the following (Por favor revise si su hijo recibe lo siguiente)

Fluoride Tablets/Drops (Gotas De Fluoruro)

Fluoride Water (Agua Fluorada)

Fluoride In Vitamins (Fluoruro En Vitaminas)

Bottled Water (Agua Embotellada)

Well Water (Agua De Pozo)

Treatments

If recommended, I consent to fluoride varnish placement*

I consent
I decline

If recommended, I consent to x-rays*

I consent
I decline

If recommended, I consent same day treatment.*

I consent
I decline

Please note, a member of our office team will contact you prior to treatment being performed to gain verbal consent.

By electing to type your name or sign the keypad below you are agreeing to an electronic signature. Your electronic signature is the legal equivalent of your manual signature on this agreement. (Al elegir escribir su nombre o firmar el teclado a continuacion, acepta una firma electronica. Su firma electronica es el equivalente legal de su firma manual en este acuerdo.)

I agree the above is completed and accurate to the best of my knowledge. (Acepto que lo anterior es completo y preciso a lo mejor de me concocimento.)

Signature of legal guardian, full name (Firma electronica del tutor legal, nombre completo):

Electronic signature agreement (Contrato De Firma Electronica)*

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