Appleton Area School District



|For the following medical history questions, please (x) whichever applies. Your answers are for our records only and will be kept confidential in accordance with |

|applicable laws. Please note you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your child’s |

|health. This information is vital to allow us to provide appropriate care for your child. This clinic does not use this information to discriminate. |

|Medical History |

|Does your child have or has ever had any of the following conditions: |

|Yes No Unsure |Yes No Unsure |Yes No Unsure |

|ο ο ο Anemia |ο ο ο Herpes |ο ο ο Radiation Treatment |

|ο ο ο Asthma |ο ο ο High Blood Pressure |ο ο ο Chronic Ear Infections |

|ο ο ο Autism |ο ο ο HIV/AIDS |ο ο ο Pregnant (at this time) |

|ο ο ο ADHD/ADD |ο ο ο Hyperactivity | |

|ο ο ο Birth Defects |ο ο ο Kidney Disease |ο ο ο Sexually Transmitted Diseases |

|ο ο ο Bleeding Problems |ο ο ο Learning Disabilities | |

|ο ο ο Blood Disorders |ο ο ο Liver Disease |ο ο ο Hearing Loss/Impairment |

|ο ο ο Cancer |ο ο ο Mental Disability | |

|ο ο ο Cerebral Palsy |ο ο ο Muscular Dystrophy |ο ο ο Heart Conditions/Murmur |

|ο ο ο Developmental Delay |ο ο ο Psychiatric Problems | |

|ο ο ο Diabetes |ο ο ο Rheumatic Fever |ο ο ο Jaundice (not at birth) |

|ο ο ο Downs Syndrome |ο ο ο Seizures | |

|ο ο ο Emotional Problems |ο ο ο Sickle Cell Anemia |ο ο ο Delayed Speech Development |

|ο ο ο Epilepsy |ο ο ο Skin Disorders |ο ο ο Allergies: __________________ |

|ο ο ο Fainting Spells |ο ο ο Tuberculosis |___________________________ |

|ο ο ο Hepatitis |ο ο ο Tumors |____________________________ |

|Please explain all “Yes” or “Unsure” responses: |

|Please list any other problems/conditions your child may have |

|Current Medications List |

|Is your child taking any prescription medications, over the counter medications, |ο Yes ο No If yes, please list medications. |

|vitamins, natural and/or herbal dietary supplements? | |

|Medication |Reason for Taking |How Much |How Often |

| | | | |

| | | | |

| | | | |

| To the best of my knowledge, the indicated health history remains current. |

|I understand that any change in the patient’s health or medication requires that an updated form be completed. |

|I certify that I have read and understand the above. |

|I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. |

|I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made|

|in the completion of this form. |

_____________________________________/_______________________________________ Date____/____/______

(Print) parent/guardian (Signature) parent/guardian

Emergency Contact Information:

Name: __________________________________________ Relationship: _____________________

Emergency Number: _______________________________

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