Medical History Form

Please complete and return to the school office. Please note that any treatment required cannot be commenced until this form has been completed.

MM slash DD slash YYYY

Has your child ever had / Currently have of the following? Please select one.

On the "Other", write down the Details / Medications / Dosage
Hepatitis / Liver Problems(Required)

Rheumatic Fever(Required)

Diabetes(Required)

Any Heart Complaint / Treatment / Operation(Required)

Epilepsy(Required)

Asthma / Breathing Problems(Required)

Kidney Problems(Required)

History of Excessive Bleeding(Required)

Allergies to Medication / Latex / Other(Required)

Other Serious Illness / Syndrome / Condition(Required)

Developmental / Behaviour Disorders(Required)

Is your child under medical care at present?(Required)

Has your child ever had /Currently have Yes No Not Known Details/Medications/Dosage
Hepatitis /liver problems
Rheumatic fever
Diabetes
Any Heart complaint / treatment / operation
Epilepsy
Asthma / breathing problems
Kidney problems
History of excessive bleeding
Allergies to medication / latex / other
Other serious illness / syndrome / condition
Developmental / behaviour disorders
Is your child under medical care at present?

In signing this form, I acknowledge that this represents an accurate medical history. I will advise “Goldfields Teeth Express” Goldfields Family Dental of any changes to this medical history in the future. I understand that all medical details will be treated with complete professional confidentiality.

MM slash DD slash YYYY
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