PEDIATRIC HEALTH HISTORY INFORMATION 18.0 Date: Child Name (Last, First, MI): Birth Date %PatientNameLast%, %PatientNameFirst% %PatientNameMiddle% (MM/DD/YYYY) ALLERGIES - Select all that apply: Aspirin Allergy Codeine Allergy Erythromycin Allergy Food Allergy Hay Fever Penicillin Allergy Sulfa Allergy Other Allergy MEDICATIONS - Please list any medications you are currently taking including vitamins and dietary supplements Please check this box if your physician or previous dentist recommended you take antibiotics prior to your dental treatment. Please check this box if your child is taking additional medications. Bring a list to the appointment.