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SOKOLOWSKI ORTHODONTICSDAGHLIAN PEDIATRIC DENTISTRY

New Patient Health History Form

Name:_______________________________________ Date of birth: ___________________________

Have you had any of the following medical issues? Please check the appropriate boxes.

Y N Arthritis Allergies to Drugs/Foods Allergies to Latex Anemia Anxiety Disorder Blood Transfusions Cancer Convulsions or Epilepsy Congenital Heart Defect Depression Diabetes Facial/Head Injuries Handicaps/Disabilities Heart Defect/Heart Murmur Hemophilia/Abnormal Bleeding Hepatitis High Blood Pressure HIV/AIDS

Please list all medications and dosages: ___________________________________________________

_____________________________________________________________________________________

Physician’s name: _____________________________________ Phone: _________________________

Dentist’s name: _______________________________________ Phone: _________________________

Y NHospital StaysKidney/Liver ProblemsLearning DisabilitiesLiver DiseaseMitral Valve ProlapseOsteoporosisPneumoniaPregnancyRheumatic/Scarlet FeverShuntsSmokingSnoring/Sleep ApneaStrokeThyroid DisorderTuberculosisOther Issues (please list):________________________________________________________________________________________________________________________