Health History Update Patient InformationChild's Name* First Last Parent/Guardian's Name* First Last Business PhoneCell Phone*Parent/Guardian's Name First Last Business PhoneCell Phone*Date Date Format: MM slash DD slash YYYY Is your child being treated by a physician at this time?*YesNoIf yes, reason*Is there any recent change in the child's medical, dental or family history?*YesNoIf yes, explain*Is your child allergic to any food, drugs, latex, dye or anything else?*YesNoIf yes, list*Is your child taking any medication (prescription or over the counter), vitamins, or dietary supplements?*YesNoIf yes, list name, dose, frequency*Has your child had a reaction or allergy to an antibiotic, sedative, or other medication?*YesNoIf yes, list*Do you have concerns about today's appointment that you would like to bring to the doctor's attention?*YesNoIf yes*Signature of Parent or Guardian*Please check your form to make sure it is complete and press the submit button when you are done. You will see a confirmation page when your form has been successfully submitted. Thank you!