Patient Name LMale LFemale Date of Birth Date of last physical exam: _________________________________________________________________________ Weight: ______________________ Name/address/phone number of primary physician: ________ ___________________________________________________________________________ Name/address/phone number of medical specialists: _______________________________ ____________________________________________________ Is your child being treated by a physician at this time? Reason ________________________________________________________ i YES i NO Is your child taking any medication (prescription or over the counter), vitamins, or dietary supplements? List name, dose, frequency & date started _________________________ _____________________________________________ i YES i NO Has your child even been hospitalized, had surgery or a signi cant injury, or been treated in an Emergency Department.................... List date & describe ________________________________________________________________________________________ i YES i NO Has your child ever had a reaction to or a problem with an anesthetic? ………………... ……………….……………………..……… Describe: ________________________________________________________________________________________________ i YES i NO Has your child ever had a reaction or allergy to an antibiotic, sedative, fluoride, or other medication? .......... …………….. .………… List ____________________________________________________________________________________________________ i YES i NO Is your child allergic to latex or anything else such as metals, acrylic, or dye? ……………………………………………..…………... List ____________________________________________________________________________________________________ i YES i NO Is your child allergic to tree nuts, soy, Birch trees, etc.? ………………………………………………………………….………….…... List _____________________________________________________________________________________________________ i YES i NO Is your child up to date on immunizations against childhood diseases ……………………………………………………... …...…… i YES i NO Mark NO after each line if none of those conditions apply to your child. Please mark YES if your child has a history of the following conditions. For each “YES,” provide details in the box at the bottom of this list. Complications before or during birth, prematurity, birth defects, syndromes or inherited conditions … …………….. .… i YES i NO Problems with physical growth or development …………………………………………………………………………. i YES i NO Sinusitis, chronic adenoid/tonsil infections ………………………………………………………………………………. i YES i NO Large tonsils, sleep apnea/snoring, mouth breathing, or excessive gagging ……………………………………. i YES i NO Congenital heart defect/disease, heart murmur, rheumatic fever, or rheumatic heart disease …………………………… i YES i NO Irregular heart beat or high blood pressure ………………………………………………………………………………. i YES i NO RSV, Asthma, reactive airway disease, wheezing, or breathing problems ……………………………………………... i YES i NO Frequent colds or coughs, or pneumonia ………………………………………………………………………………… i YES i NO Is there anyone in the child’s life who smokes? ………………………………………………………………………… i YES i NO Jaundice, hepatitis, or liver problems …………………………………………………………………………………….. i YES i NO Gastroesophageal/acid re ux disease (GERD), stomach ulcer, or intestinal problems ………………………………….. i YES i NO Lactose intolerance, food allergies, nutritional de ciencies, or dietary restrictions …………………………………... i YES i NO Prolonged diarrhea, unintentional weight loss, concerns with weight, or eating disorder ……………………………….. i YES i NO Bladder or kidney problems ……………………………………………………………………………………………… i YES i NO Arthritis, scoliosis, limited use of arms or legs, or muscle/bone/joint problems ………………………………………… i YES i NO Rash/hives, eczema or skin problems ……………………………………………………………………………………. i YES i NO Impaired vision, hearing or speech ………………………………………………………………………………………. i YES i NO Developmental disorders, learning problems/delays, or intellectual disability ……………………………………….. i YES i NO Cerebral palsy, brain injury, epilepsy, or convulsions/seizures ………………………………………………………….. i YES i NO Autism/autism spectrum disorder ………………………………………………………………………………………… i YES i NO Recurrent or frequent headaches/migraines, fainting, or dizziness ………………………………………………………. i YES i NO Hydrocephaly or placement of a shunt (ventriculoperitoneal,ventriculoatrial, ventriculovenous) ………………… i YES i NO Attention de cit/hyperactivity disorder (ADD/ADHD) …………………………………………………………………. i YES i NO Behavioral, emotional, communication, or psychiatric problems/treatment …………………………………………….. i YES i NO Abuse (physical, psychological, emotional, or sexual) or neglect ……………………………………………………….. i YES i NO Diabetes, hyperglycemia, or hypoglycemia ……………………………………………………………………………… i YES i NO Precocious puberty or hormonal problems ………………………………………………………………………………. i YES i NO Thyroid or pituitary problems……………………………………………………………………………………………. i YES i NO Anemia, sickle cell disease/trait, or blood disorder ……………………………………………………………………… i YES i NO Hemophilia, bruising easily, or excessive bleeding ……………………………………………………………………… i YES i NO Transfusions or receiving blood products ………………………………………………………………………………... i YES i NO Cancer, tumor, other malignancy, chemotherapy, radiation therapy, or bone marrow or organ transplant ………....... i YES i NO Mononucleosis, tuberculosis (TB), scarlet fever, cytomegalovirus (CMV), methicillin resistant staphylococcus aureus (MRSA), sexually transmitted disease (STD), or human immunode ciency virus (HIV)/AIDS …………… .. ………… i YES i NO PROVIDE DETAILS HERE: ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ OVER Dr. Gremillion New Patient Medical History-Form Dino Smiles