Medical History

Are you child's immunizations up to date?

Yes No

Has your child ever been hospitalized or had a surgery?

Yes No

If yes, please explain:

Is your child taking any PRESCRIPTION medications?

Yes No

If yes, please list:

Is your child taking any over the counter medications, vitamins or supplements?

Yes No

If yes, please list :

Does your child have any drug allergies?

Yes No

If yes, please list:

Does your child have any other non drug allergies (seasonal, food etc.)?

Yes No

If yes, please list:

Has your child ever had any of the following conditions?

Please give more details (date, outcome) of any checked items:

Were there any complications or problems during pregnancy or delivery?

Yes No

If yes, please explain:

Describe your child's current physical health:

Good Fair Poor

Digital Signature

I understand that the information I have given is correct to the best of my knowledge and that it is my responsibility to inform this office of any changes in my child's medical status.

Hours

Meredith Kurysh, DDS