Children's New Patient Information Form

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Does your child have any serious Medical Conditions we should know about?*
- Yes
- No
Please explain.
Known Medical Conditions
- Alcohol/ Drug Abuse
- Angina
- Arthritis
- Asthma
- Blood Disorder
- Cancer
- Chemotherapy
- Congenital Heart Defect
- Diabetes
- Dizziness/Fainting
- Emphysema
- Epilepsy/Seizures
- Frequent Headaches
- Gag Reflex
- Hay Fever
- Head Injuries
- Hearing Disabled
- Heart Attack
- Heart Murmur
- Hemophilia
- No Known Medical Issues
Please select each Medical Condition that is applicable for you!
Known Medical Conditions cont'd
- Hepatitis A/B/C
- High Blood Pressure
- HIV/AIDS
- Joint Replacement (hip, knee, etc)
- Kidney Disease
- Liver Disease
- Low Blood Pressure
- Lung Disease/ Tuberculosis
- Mental Disorder
- Mitral Valve Prolapse
- Multiple Sclerosis
- Pacemaker
- Radiation Therapy
- Respiratory Problems
- Sinus Problem
- STD
- Stomach/Intestinal Problems
- Stroke
- Thyroid Disorder
- Ulcer
- Other
If Other selected, please specify:*
Does your child have any allergies to medication or substances?*
- Yes
- No
What Allergies do you have?
Is your child taking any prescription medication or herbal remedies?*
- Yes
- No
Please list off your child's medications*
Does your child need to be medicated with antibiotics prior to dental treatment*
- Yes
- No
Has your child been treated for any other illness not listed above?*
- Yes
- No

Full Name of Legal Guardian/Parent responsible for the form*
First Name Last Name
Consent*
I affirm that the information that I have given is correct to the best of my knowledge. It will be held in the strictest of confidence and it is my responsibility to inform this office of any changes to my health or medical status. I authorize North Stony Dental to preform any necessary dental services that I may need.
Signature*

Dentistry Made Simple.

403-452-2833
reception@parkwaysmiles.ca

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