• Pediatric Dentistry Health History and Patient Information

    This confidential information is of great value in aiding us to better understand and treat your child
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  • Birth Sex*
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  • Is your child being treated by a physician at this time?*
  • Is your child taking any medication (prescription or over the counter), vitamins, or dietary supplements?*
  • Has your child ever been hospitalized, had surgery or a significant injury, or been treated in an emergency department?*
  • Has your child ever had a reaction to or problem with an anesthetic?*
  • Has your child ever had a reaction or allergy to an antibiotic, sedative, or other medication?*
  • Is your child allergic to latex or anything else such as metals, acrylic, or dye?*
  • Is your child up to date on immunizations against childhood diseases?*
  • Is your child adopted?*

  • Please mark "Yes" if your child has a history of the following conditions. For each "Yes", provide details at the bottom of this list where indicated. Mark "No" after each line if none of those conditions applies to your child.

  • Complications before or during birth, prematurity, birth defects, syndromes, or inherited conditions*
  • Problems with physical growth or development*
  • Sinusitis, chronic adenoid/tonsil infections*
  • Sleep apnea/snoring, mouth breathing, or excessive gagging*
  • Congenital heart defect/disease, heart murmur, rheumatic fever, or rheumatic heart disease*
  • Irregular heart beat or high blood pressure*
  • Asthma, reactive airway disease, wheezing, or breathing problems*
  • Cystic fibrosis*
  • Frequent colds or coughs, or pneumonia*
  • Frequent exposure to tobacco smoke*
  • Jaundice, hepatitis, or liver problems*
  • Gastroesophageal/acid reflux disease (GERD), stomach ulcer, or intestinal problems*
  • Lactose intolerance, food allergies, nutritional deficiencies, or dietary restrictions (please list at bottom)*
  • Prolonged diarrhea, unintentional weight loss, concerns with weight, or eating disorder*
  • Bladder or kidney problems*
  • Fine/gross motor deficits, arthritis, limited use of arms or legs, muscle/bone/joint problems, or scoliosis*
  • Rash/hives, eczema, or skin problems*
  • Impaired vision, visual processing, hearing, or speech*
  • Developmental disorders, learning problems/delays, or intellectual disability*
  • Cerebral palsy, brain injury, epilepsy, or convulsions/seizures*
  • Autism/autism spectrum disorder*
  • Recurrent or frequent headaches/migraines, fainting, or dizziness*
  • Hydrocephaly or placement of a shunt (ventriculoperitoneal, ventriculoatrial, ventriculovenous)*
  • Attention deficit/hyperactivity disorder (ADD/ADHD)*
  • Behavioral, emotional, communication, or psychiatric problems/treatment*
  • Abuse (physical, psychological, emotional, or sexual) or neglect*
  • Diabetes, hyperglycemia, or hypoglycemia*
  • Precocious puberty or hormonal problems*
  • Thyroid or pituitary problems*
  • Anemia, sickle cell disease/trait, or blood disorder*
  • Hemophilia, bruising easily, or excessive bleeding*
  • Transfusions or receiving blood products*
  • Cancer, tumor, or other malignancy; chemotherapy, radiation therapy, or bone marrow or organ transplant*
  • Mononucleosis, tuberculosis (TB), scarlet fever, cytomegalovirus (CMV), methicillin resistant staphylococcus aureus (MRSA), sexually transmitted disease (STD), or human immunodeficiency virus (HIV)/AIDS*
  • Is there any other significant medical history pertaining to this child or his/her family that the dentist should be told?*
  • How would you describe your child's oral health?*
  • How would you describe your oral health?*
  • How would you describe the oral health of your other children?*
  • Is there a family history of cavities?*
  • Indicate all that apply:
  • Does your child have a history of any of the following? Please mark any of the following that apply:
  • Sucking habit after one year of age?*
  • If yes, which?
  • Does someone help your child brush?*
  • How often does your child floss his/her teeth?*
  • Does someone help your child floss?*
  • What is the source of your drinking water at home?*
  • Do you use a water filter at home?*
  • Please check all sources of fluoride your child receives:

  • Does your child regularly eat 3 meals each day?*
  • Is your child on a special or restricted diet?*
  • Is your child a "picky eater"?*
  • Does your child have a diet high in sugars or starches?*
  • Do you have any concerns regarding your child's weight?*
  • Does your child participate in any sports or similar activities?*
  • Does your child wear a mouth guard during these activities?*
  • Has your child been examined or treated by another dentist?*
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  • Were x-rays taken of the teeth or jaws?*
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  • Has your child ever had orthodontic treatment (braces, spacers, or other appliances)?*
  • Has your child ever had a difficult dental appointment?*
  • How do you expect your child will respond to dental treatment?*
  • Is there anything else we should know before treating your child?*
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  • SUPPLEMENTAL HISTORY QUESTIONS FOR AN INFANT/ TODDLER

    (complete if your child is under 3 years old)
  • Was your child born prematurely?
  • How long was your child breast-fed?
  • How long was your child bottle-fed?
  • Do/did you feed your child infant formula?
  • If yes, what type?
  • Does/did your child sleep with a bottle or breastfeed (co-sleep)?
  • Does/did your child use a no-spill training cup (sippy cup)?
  • Has your child experienced any teething problems?
  • When did you begin brushing his/her teeth?
  • When did you begin using toothpaste?

  • Please acknowledge the following:

  • Check the following to acknowledge:*
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  • Should be Empty: