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.

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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)


Any Heart Complaint / Treatment / Operation(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
Any Heart complaint / treatment / operation
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.

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