Child Medical History Form

Child Medical History Form

(For child up to 12 years old) Welcome to Dental as Anything where we provide individualized care for infants, toddlers, children and teens. Our focus is on prevention and early management of dental disease. We are honoured that you have entrusted your child’s care to us. We take great pride in providing a comfortable experience for children and their families. Should you have any special requests, please inform us and we will do our best to accommodate you.
How did you find us?*

Patient or FriendFacebookProfessionalFamilyPractice WebsiteStaff at DAASignageGoogleOther
Who may we thank for referring you?*
Please let us know how you did find us?*
What did you type in to search for on Google?*
Tell us about your child
Surname*
Given Name*
Preferred Name
What your child likes to be called
Date of Birth*

DayMonthYear
Age*
How many years old are you?
Name of school?*
Residential Address*

Street Address

Street Address Line 2

SuburbState

Postcode
Mobile Phone (Parent or Guardian):*
Home Phone (Parent or Guardian):
Favourite movie?
Favourite song or band?
Favourite activity
Do you have Private Health Insurance?*

NoYes
Name of Private Health Fund?*
Position (Line No) on the card?*
usually 1 or 2 digits
Medicare Card Number*
10 digits
Position (Line No) on medicare card?*
usually 1 or 2 digits
Expiry date on medicare card?*
Month / Year
Parent or Guardian Contact Details
Name - Parent (1) or Guardian:*
Phone No - Parent (1) or Guardian:*
Email - Parent (1) or Guardian:*
Name - Parent (2) or Guardian:
Phone No - Parent (2) or Guardian:
Email - Parent (2) or Guardian:
Who is accompanying your child today?*
Relationship to child?*
Do you have legal custody of this child?*

NoYes
Medical History
Please indicate your child's current general health?*

ExcellentGoodFairPoor
Name of your Child's Doctor (General Practitioner)
Doctor Phone:

Has your Child ever had any of the following?*

	Yes	No
Kidney or liver conditions?
Blood disorders?
Sickle cell disease?
Cancer?
Heart disease or murmur?
HIV+ / AIDS?
Rheumatic / scarlet fever?
Asthma?
Congenital birth defects?
Autism?
Epilepsy?
Tuberculosis?
Abnormal bleeding?
Hearing impairment?
ADD / ADHD?
Disablilities or special needs? (describe below)

Does your Child have any other disease/condition(s) not listed above? Please enter details:
Child Diabetes?*
Child Hepatitis?*
Is your Child allergic to anything? (eg: latex, penicillin, local anaesthetic, peanuts, etc.)*

NoYes
Please list what you are allergic to:*
Is your Child currently taking any medications? (including any natural remedies)*

NoYes
Please list what medications or natural remedies you are taking:*
Has your Child been hospitalised in the last 12 months?*

NoYes
Please describe for what?:*
Dental History
Is this your Child's first dental visit?*

NoYes
When was your Child's last dental visit?*
Did your Child have any x-rays taken at their previous dental visits?*

NoYesI don't know
Has your Child had any injuries to the teeth, face or mouth*

NoYes
Please give details about the injuries:*
Is there a history of family dental problems?*

NoYes
Please describe the family dental issues::*
Why did you bring your Child to the dentist today?
Do have any dental concerns or questions regarding your Child?

NoYes
Please list your concerns or questions:*
Have the previous dental visit with your Child been ?

PositiveNegative
Please describe why it was negative:*
Do any of the following apply to your Child? :

Frequent snackingSleeping with a bottlePacifier useBreast-feedingTooth grindingThumb sucking
During the day, how many cups would your Child drink of:

Juice: cups* per day
Milk: cups* per day
Fizzy drinks: cups* per day
At night time, how many cups would your Child drink of:

Juice: cups* at night
Milk: cups* at night
Fizzy drinks: cups* at night
Is there anything we can do to make your Child more comfortable at our practice?

Dental care at home*

	Yes	No
Does your Child brush his or her own teeth?
Does your Child have difficulty brushing his or her teeth?
Does your Child us xylitol products?
Does your Child floss daily?
Do you floss your Child's teeth?
Does your Child use fluoride toothpaste?
Is your Child taking fluoride supplements?
Is your Child able to spit?

Consent for Treatment & Communications*

I am happy to receive SMS and Email communication from Dental as Anything for critical or pertinent appointment reminders and any other information that pertains to dental awareness, health fund or governmental changes.I hereby consent to dental treatment deemed necessary by the dentists and agreed by my verbal consent beforehand to be carried out. I understand that it will be discussed with me before any staff takes x-rays, study models, photographs and other diagnostic aids deemed appropriate by the dentist to make a thorough diagnosis.I agree to be responsible for the payment of all services rendered on my behalf and on behalf of my dependants. I understand that payments are due at the time of service.
Signature of Patient or Guardian*

Clear
Name of Parent or Guardian
Today's Date*

DayMonthYear
Date signed
Should be Empty:

Child Medical History Form

Tell us about your child

Parent or Guardian Contact Details

Medical History

Dental History