Patient Registration/Health History Update  
 
Child's first name
Child's last name
Any changes in your address, phone number or e-mail?
no yes
Indicate changes
Primary Dental Insurance
No dental insurance no changes
Insurance Company
Phone number
Group number
Subscriber/Policy Holder
Subscriber Identification (often SSN)
Subscriber's DOB
Subscriber's employer
Secondary Dental Insurance
No secondary insurance no changes
Insurance Company
Phone number
Group number
Subscriber/Policy Holder
Subscriber Identification (often SSN)
Subscriber's DOB
Subscriber's employer
Medical Information
 
Have there been any changes in your child's health?
no yes
Health changes:
Has your child been hospitalized?
no yes
Date of hospitalization(s)
What for?
Has your child had surgery?
no yes
Date of surgery(ies)
What for?
Has your child ever had a blood transfusion?
no yes
 
Immunization status
up to date
not up to date
prefer not to immunize
   
Is your child taking any medication (over the counter or prescription)?
no yes
Name of medication
Dose
What for?
Is your child taking any natural herbs/remedies/ tinctures/supplements?
no yes
Name of herbs/remedies/tinctures/supplements and why they are being taken
 
medication/drugs?
no yes
latex?
no yes
foods?
no yes
Please describe allergy(ies)
Is you child allergic to:
 
 
   
What are your child's sources of fluoride?
water toothpaste
supplement rinse
gel none
family prefers no fluoride
   
Teenage Girls Only
 
Some antibiotics may reduce the effectiveness of birth control pills. Some medications may affect an unborn fetus.
Are you pregnant?
no yes
Are you taking birth control pills?
no yes
Do you get a birth control shot?
no yes
 
Any additional comments?
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I have read and understand the questions on the registration/medical information update form and have answered the questions truthfully and to the best of my ability. I agree to notify Dr. Woo of any additional changes.

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