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Health Protocols
Our Practice
Services
New Patients
Current Patients
Contact
Privacy Policy
Dr. Todd J. Ayars, DDS PA Patient Medical History Form
536 E. Pleasant Run Rd. Desoto, TX. 75115 | 972-296-9976
Child's Name
*
Date of Birth
*
/
Month
/
Day
Year
Cell Phone
*
Email
*
Is your child taking any medications?
*
Yes
No
If yes, please list names and dosages
*
Has your child had any reactions or allergies to any medicines?
*
Yes
No
If yes, please list
*
Has your child had any of the following medical problems?
*
None
Recurrent headaches
Food allergies/Hayfever
Hepatitis/Jaundice
Tumors/malignancies
Asthma/lung problems
HIV positive/AIDS
Behavior/learning difficulties
Eye disorders
Difficulty with speech/hearing
Kidney/liver problems
Birth defects/cleft lip or palate
Blood transfusion
Epilepsy/seizure disorder
Rheumatic fever
Prolonged bleeding/Hemophilia
Trauma/injury
Handicaps/disabilities
Hospital/surgery
Diabetes
Recurrent infections
Heart disease/heart murmur
Disorder of the endocrine system
Tuberculosis
Leukemia
Problems with jaw joint (TMJ/TMD)
Signature:
*
Clear
Date:
*
-
Month
-
Day
Year
Relationship:
*
Submit
Should be Empty:
