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Patient`s Name*  
Dr. Ashley Starnes
Dr. Jason Bongiovi
Patient Medical History
Is your child currently under the care of a physician/pediatrician?  
Yes No 

If yes, what is the name of the doctor/practice?  
Is your child currently taking any medication?*  
Yes No 

If yes, please list them:  
Is your child allergic to any medicines or food?*  
Yes No 

If yes, please list:
  
Is your child allergic to latex?*  
Yes No 

Has your child ever had any surgery (including ear tubes, tonsils and adenoids, etc)?  
Yes No 

If yes, please list surgeries:  
Check any of these conditions in which your child presently has or has previously had:
 
  Anemia 
  Ear Disorders 
  Hyperactivity 
  Premature Birth 
 
  Asthma 
  Seizure Disorders 
  Cerebral Palsy 
  Rheumatic Fever 
 
  Bleeding Problems 
  Eye Disorders 
  Kidney Disease 
  Stomach Problem 
 
  Bone Disorder 
  Autism 
  Liver Disease 
  COVID exposure 
 
  Brain Disorder 
  Heart Condition 
  Lung Disease 
  Speech Problem 
 
  Shunt 
  Heart Murmur 
  Developmental Delay 
  HIV Positive 
 
  Cancer 
  High Blood Pressure 
  Muscle Disorder 
 
  Diabetes 
  Hormone Disorder 
  Downs Syndrome 
 
  Other Conditions not listed above 
 
 
Please specify for applicable conditions:  
Is this your child`s first visit to the dentist?  
Yes No 

Please list most current dates and services performed:  
What is your main concern about your child`s teeth?*  
Has your child ever had any injuries to the mouth or face area?*  
Yes No 

Does your child have any of the following habits: finger/thumb sucking, pacifier?  
Yes No 

Additional Comments:  
I certify that the above information is accurate and complete to the best of my knowledge. I understand that any errors or omissions could harm my child`s dental treatment and/or their overall health. I will not hold Dr. Bongiovi, Dr. Starnes or their staff responsible for the result of any errors or omissions in the information l have provided on this form.
 
Legal Guardian/Patients Signature:*  
Date*  
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