Name(Required) First Last Email(Required) Phone(Required)Date of Birth(Required) Month Day Year WeightHeightHas your child ever been in a hospital?(Required) Yes No If so, when and why?(Required)Was your child born prematurely?(Required) Yes No If so, what was their premature weight?(Required)Has your child ever had general anesthesia or surgery?(Required) Yes No If so, when and detail any problems or complications?(Required)Has anyone in your family or relatives had a problem during or after an anesthetic?(Required) Yes No If yes, please explain any test done.(Required)Has anyone in your family tested positive for Maligant Hyperthermia?(Required) Yes No If yes, what was there relation and what tests were performed?(Required)Does your child have any drug allergies?(Required) Yes No What type of drug(s)?(Required)Does your child have other allergies?(Required) Yes No What are the symptoms?(Required)Skin Rash(Required) Yes No Hives(Required) Yes No Wheezing or trouble breathing(Required) Yes No If yes, what was done to treat the problem?(Required)Does your child wear a dental plate/bridge/retainer/braces?(Required) Yes No Does your child have any damaged or loose teeth?(Required) Yes No Does your child take ANY medications currently?(Required) Yes No Please list the medications and dose.(Required)Does your child use or take ANY non-prescription remedies?(Required) Yes No Please list them including name and does.(Required)Has your child had a cortisone (steroid) type drug in the past year?(Required) Yes No Please list the reason and how long it was taken.(Required)Is there anyone in the family with a bleeding problem?(Required) Yes No Has your child had an excessive amount of bleeding following surgery such as tooth extraction?(Required) Yes No Does your child bruise easily on areas other than the legs?(Required) Yes No Does your child have any difficulty with head/neck/jaw movement?(Required) Yes No Does your child have problems with muscles/joints/nervous system?(Required) Yes No Has your child been exposed to any infectious diseases in the past month?(Required) Yes No Does your child have or ever had any of the following? Please check all that apply. Anemia Arthritis Asthma Convulsions Croup Cystic Fibrosis Developmental Delay Diabetes Epilepsy GE Reflux Glaucoma Heart Disease Hepatitis High Blood Pressure Jaundice Kidney Disease Liver Disease Lung Disease Malignant Hyperthermia New Option Seizures Tuberculosis Select AllDoes anyone in the home smoke?(Required) Yes No Are there any problems with your child's health not covered?(Required) Yes No Additional commentsParent/Guardian Name First Last
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