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  • CHILD MEDICAL AND DENTAL HISTORY

    Every individual child will need this form completed
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  • DENTAL HISTORY

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  • Has patient had an injury to the mouth, teeth or jaw? 
       *   
    If Yes, please explain:
       

  • DOES YOUR CHILD CURRENTLY...

    Please check all that apply
  • HYGIENE ROUTINE

    Please check all that apply
  • Does child brush their own teeth?
          *      
     If yes, how many times a day      

  • Does parent help brush teeth for child?
        *   
    If yes, how many times a day      

  • Does child use Dental Floss?
           *   
    If yes, how many times a week?
       

  • Does your child snack between meals?
            *          
    If yes, what types of snacks?  
        

  • Does your child drink juice?
          *   
    If Yes, how many cups of juice does your child drink daily?
       

  • MEDICAL HISTORY

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  • ALLERGIES

  • Is your child allergic to any medications?
           *   
    If Yes, then what medications are they allergic too?  
      ,      ,        

  • Is your child allergic to Latex?
           *   

  • Is your child allergic to any foods?  
        *   
    If Yes, then what foods are they allergic too?
                      

  • Does your child get seasonal allergies?
          *   

  • Does your child have or get Hives?
          *   

  • Does your child have any other allergies? 
         *            
    If Yes, List what other allergies they have:
                   

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

  • MEDICATIONS

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

  • HOSPITALIZATIONS/SURGERY

  • 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.

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  • ADK MDH

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