Alison K Jackson, DDS - Health History Update
Please complete the following form before you arrive for your appointment. Press submit when you are finished and the form will upload to our office (no paper needed.) . If you have any questions please call our office at 831-662-2900.

The purpose of this form is to document any changes or updates to your child's health before their current visit. This form is to be filled out by existing patients who have already submitted a complete health history.
Date of upcoming APPOINTMENT:
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DD
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Patient's First Name: *
Patient's Last Name: *
If there have been any changes in your child's health since the last visit please explain below. If there have been no changes, please write "none." *
If your child has any current illness, please list below. If no illness, please write "none." *
Please list ALL medications your child is taking. If they are not taking any medications, please write "none." *
Please list all allergies. If your child has no allergies, please write "none." *
Has your child been hospitalized since their last visit? *
Required
Please list any questions or concerns you have about your child's oral health.
𝗣𝗮𝗿𝗲𝗻𝘁/𝗚𝘂𝗮𝗿𝗱𝗶𝗮𝗻 𝗦𝗶𝗴𝗻𝗮𝘁𝘂𝗿𝗲 - By entering your full name in the box below, you are effectively providing your signature, indicating that all the information on this form is true and accurate, to the best of your knowledge. *
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