PEDIATRIC HEALTH HISTORY INFORMATION 18.0 Date: Child Name (Last, First, MI): Birth Date %PatientNameLast%, %PatientNameFirst% %PatientNameMiddle% (MM/DD/YYYY) Physician / Medical Clinic Name: Last Physical Exam: Select The Appropriate Answer Is your child under the care of a medical doctor at this time? No Yes Has your child ever been hospitalized? No Yes Has your child had any excessive bleeding requiring special treatment? No Yes Are your child's immunizations current? No Yes Do you or your child smoke or use tobacco products? No Yes ALLERGIES - Select all that apply: Aspirin Allergy Codeine Allergy Erythromycin Allergy Food Allergy Hay Fever Penicillin Allergy Sulfa Allergy Other Allergy Has your child taken any medications or drugs in the past two years? No Yes Is your child taking any vitamins / herbal supplements / holistic remedies? No Yes 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.