Patient First Name: *

Patient Middle Name:

Patient Last Name: *

Date of birth: *

Age

Name of Child's Physician?:

Child Physician's Phone Number:

Any problems/complications durning pregnancy/delivery? If yes, please explain: *

Does your child have any health problems? If yes, please explain: *

Has your child been diagnosed with any medical conditions? If yes, please explain: *

Has your child ever been hospitalized? If yes, please explain (For & When): *

Has you child ever had surgery? If yes, please explain (For & When): *

Is your child taking any medication? If yes, please list: *

Is your child allergic to any medications/food/latex? If yes, please list: *

Are your child's immunizations up to date?: *

Main reason for today's visit?:

History of Dental Trauma? If yes, please explain:

Is there any additional medical/dental information you may want the dentists at Hi5 Dental to know?