Medical History Form for Children

Medical History Form for Children

Patient’s Name (*)

Today’s Date (*)

Parent/Guardian Name (*)

Have you ever been put under anesthesia before? (*)

If yes, for what type of procedure?

Where and When?

Did you experience any complications?

Have you ever had surgery? (*)

If yes, what type of surgery?

Where and When?

Did you experience any complications?

Have you ever been hospitalized? (*)

If yes, for what reason?

Where and When?

How many days?

Please check the box for any of the following conditions which may apply to you now or have applied to you in the past: (*)










































Do you smoke cigarettes or use smokeless tobacco? (*)

If yes, how many packs per day?

Are you allergic to any medications such as local anesthetic, Penicillin, Erythromycin, Codiene, Aspirin, Sulfa, or any other medication? (*)

If yes, please explain

What medications are you currently taking? (*)

When was the last time you were sick with a cold, cough or fever? (*)

there anything that we haven’t asked that you feel would be important for us to know?

Asthma/ bronchitis (*)

Did the child come home at the same time as the mother? (*)