ADFK_Medical and Dental History

First Name Last Name

(Example: Child's Legal Name is Suzanna, but they prefer to be called Suzie)

Silverton Keizer Corvallis Hillsboro West Salem

Cleaning/Exam Trauma/Dental Emergency Consult for Decay (Cavities) Second Opinion

If today is their first exam, put today's date

Has patient had an injury to the mouth, teeth or jaw?
Yes No*
If Yes, please explain:

Outgoing Shy Stubborn Anxious Frightened Age-Appropriate Other

Suck Thumb/finger Suck/Bite Lips Bite/Chew Nails Use Pacifier Clench/Grind Teeth Breathe through mouth primarily None of These

Fluoride Toothpaste Consume Fluoridated Water Fluoride Mouthwash Fluoride Supplement Other:

Does child brush their own teeth?
Yes No*
If yes, how many times a day

Does parent help brush teeth for child?
Yes No*
If yes, how many times a day

Does child use Dental Floss?
Yes No*
If yes, how many times a week?

Does your child snack between meals?
     Yes   No*
If yes, what types of snacks?

Does your child drink juice?
Yes No*
If Yes, how many cups of juice does your child drink daily?

Is your child allergic to any medications?
    Yes   No*
If Yes, then what medications are they allergic too?
  ,      ,

Is your child allergic to Latex?
Yes No*

Is your child allergic to any foods?
Yes   No*
If Yes, then what foods are they allergic too?

Does your child get seasonal allergies?
Yes No*

Does your child have or get Hives?
Yes No*

Does your child have any other allergies?
  Yes   No*
If Yes, List what other allergies they have:


Please add any additional comments or details about your child's allergies:

List all medications/natural remedies that your child is taking:
Name:   Dose:    Frequency:
Name:   Dose:    Frequency:
Name:   Dose:    Frequency:

If yes, please complete the following:
Hospital Facility: Reason: Date:
Hospital Facility: Reason: Date:

The information I have given is correct to the best of my knowledge. I understand that providing incorrect information can be dangerous to my child's health. I understand that it is my responsibility to inform Acorn Dentistry for Kids of any changes in medical status.

CHILD MEDICAL AND DENTAL HISTORY

DENTAL HISTORY

DOES YOUR CHILD CURRENTLY...

HYGIENE ROUTINE

MEDICAL HISTORY

ALLERGIES

MEDICATIONS

HOSPITALIZATIONS/SURGERY

ADK MDH