Children's Medical History
Patient Name
*
First Name
Last Name
Date of Birth
*
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Year
Dental History
Is this the child’s first visit to a dentist?
*
Yes
No
Does the child snore?
*
Yes
No
Does the child grind teeth?
*
Yes
No
Are there issues with the tonsils (such as enlarged)
*
Yes
No
Does the child have any habits such as Pacifier / thumb / finger sucking?
*
Yes
No
Dos the child have a bottle or sipper cups or speech issues?
*
Yes
No
Do you live in an area without fluoridated water?
*
Yes
No
Has the child had any unfavorable dental experiences?
*
Yes
No
If "Yes" Please Explain
*
Medical History
Is the child in good health?
*
Yes
No
The child had any serious illness?
*
Yes
No
When?
*
What?
*
Has the child had surgery?
*
Yes
No
Does your child have any medical concerns we should be aware of?
*
Yes
No
If "Yes" Please Explain
*
Is the child subject to
Disorders
*
Yes
No
Seizures
*
Yes
No
ADD / ADHA
*
Yes
No
Depression
*
Yes
No
Anxiety
*
Yes
No
Dizziness?
*
Yes
No
Fainting?
*
Yes
No
Does the child have allergies?
*
Yes
No
Medications
*
Yes
No
What?
*
Latex
*
Yes
No
Other
*
Yes
No
If "Other" Please Explain
*
Does the child have any of the following problems?
Heart Issues
*
Yes
No
Liver
*
Yes
No
Kidney
*
Yes
No
Lung
*
Yes
No
Is the child taking any medication?
*
Yes
No
What?
*
When?
*
Why?
*
Parent Signature
*
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
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