Medical History Update – Frontier Kids Dentistry

Medical History Update Form

Today's Date

Child's Name

First Name

Last Name

Age

Weight

Child's favorite movie

Parent's Name

First Name

Last Name

Relationship to child

Please provide us with any changes to your contact information since last visit:

Please provide us with any changes to your dental insurance:

Name of Pediatrician

Please list any allergies

Any changes to your child's health since last visit?

Any particular concerns for your child's teeth?

Has your child had any trauma to the mouth, teeth or jaws since last visit?

Is there anything else we should know before treating your child?