Patient Name *

First Name

Last Name

Please provide name and number of your child's pediatrician AND any other doctor he/she is seeing. *

Yes

No

Has your child ever been hospitalized or had a major operation? *

Yes

No

Is your child on a special diet? *

Yes

No

Is your child allergic to any of the following?

Aspirin

Latex

Acrylic

Penicillin

Sulfa Drugs

Local Dental Anesthetics

Codeine

Demerol or Phenergan

Metal

Valium

Is your child taking any medications, inhalers, vitamins, pills, or drugs? *

Yes

No

AIDS/HIV Positive *

Yes

No

Diabetes *

Yes

No

Hepatitis B or C *

Yes

No

Rheumatic Fever *

Yes

No

Epilepsy or Seizures *

Yes

No

Excessive Bleeding *

Yes

No

Excessive Thirst *

Yes

No

Fainting Spells/Dizziness *

Yes

No

Frequent Cough *

Yes

No

Frequent Diarrhea *

Yes

No

Frequent Headaches *

Yes

No

Low Blood Pressure *

Yes

No

Thyroid Disease *

Yes

No

Tonsillitis *

Yes

No

Cold Sores/Fever Blisters *

Yes

No

Congenital Heart Disorder *

Yes

No

Psychiatric Care *

Yes

No

Cortisone Medicine *

Yes

No

Hepatitis A *

Yes

No

Renal Dialysis *

Yes

No

High Blood Pressure *

Yes

No

High Cholesterol *

Yes

No

Hives or Rash *

Yes

No

Hypoglycemia *

Yes

No

Irregular Heartbeat *

Yes

No

Kidney Problems *

Yes

No

Leukemia *

Yes

No

Liver Disease *

Yes

No

Cancer *

Yes

No

Chemotherapy *

Yes

No

Heart Attack/Failure *

Yes

No

Heart Murmur *

Yes

No

Parathyroid Disease *

Yes

No

ADD/ADHD *

Yes

No

Hemophilia *

Yes

No

Recent Weight Loss *

Yes

No

Anemia *

Yes

No

Rheumatism *

Yes

No

Scarlet Fever *

Yes

No

Shingles *

Yes

No

Sickle Cell Disease *

Yes

No

Sinus Trouble *

Yes

No

Spina Bifida *

Yes

No

Stomach/Intestinal Disease *

Yes

No

Stroke *

Yes

No

Glaucoma *

Yes

No

Hay Fever *

Yes

No

Osteoporosis *

Yes

No

Autism Spectrum *

Yes

No

Ulcers *

Yes

No

Jaundice (not at birth) *

Yes

No

Radiation Treatments *

Yes

No

Anaphylaxis *

Yes

No

Cold Sores/Fever Blisters *

Yes

No

Arthritis/Gout *

Yes

No

Artificial Heart Valve *

Yes

No

Artificial Joint *

Yes

No

Asthma *

Yes

No

Blood Disease *

Yes

No

Blood Transfusion *

Yes

No

Breathing Problems *

Yes

No

Bruise Easily *

Yes

No

Lung Disease *

Yes

No

Mitral Valve Prolapse *

Yes

No

Tuberculosis *

Yes

No

Tumors or Growths *

Yes

No

Heart Trouble/Disease *

Yes

No

Pregnant *

Yes

No