770-343-4702 Medical History Form Are you in the Office or at Home?* Office Home Preferred Dentistry for Children Location* Select Location Austell Douglasville Buford Woodstock Cumming Patient Name* Date of Birth* MM slash DD slash YYYY 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 Other drugs (Otras drogas) Yes No Nuts (Nueces) Yes No Other food or fruit (Otros almentos o frutos) Yes No Seasonal/environmental (Ambiental/estacional) Yes No 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 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)* Associations & Partners Pediatric Dentists in Georgia Dentists Services Parents What’s New Georgia Pediatric Dental Care Emergencies Patient Forms Special Offers Your First Visit Contact Dentistry for Children Georgia Careers Reviews Privacy Notice Subscribe to our newsletter Have an Emergency? Get Help Copyright 2021 | All rights reserved. Site by Trew Knowledge. Powered by WordPress VIP.