Maile S.C. Kim DDS, Bren M. Chun DDS

642 Ulukahiki St., Suite 308 Kailua, Hawaii 96734-4439

808-261-5354

HEALTH HISTORY UPDATE

Patient Name:
Date of Birth:
Phone:
Email:

Has your child ever had any of the following?
If yes, please explain & note if the issue has since been resolved:
Is your child allergic or sensitive to any foods or medications?
If yes, please indicate & note reaction:
Does your child take any medication regularly, or is he/she taking any medication(s) now?
If yes, please indicate medication & dose:
How does your child receive fluoride?

To the best of my knowledge the above questions have been accurately answered.

Signature:

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Date:
Relationship:

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