Child Medical History Form

  • Child Medical History Form

  • (For child up to 18 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?*

  • Tell us about your child

  • Date of Birth*
     / /
  • Format: 0000 000 000.
  • Format: (00) 0000-0000 .
  • Do you have Private Health Insurance?*

  • Parent or Guardian Contact Details

  • Do you have legal custody of this child?*

  • Medical History

  • Please indicate your child's current general health?*
  • Rows
  • Rows
  • Is your Child allergic to anything? (eg: latex, penicillin, local anaesthetic, peanuts, etc.)*
  • Is your Child currently taking any medications? (including any natural remedies)*
  • Has your Child been hospitalised in the last 12 months?*

  • Dental History

  • Is this your Child's first dental visit?*
  • Did your Child have any x-rays taken at their previous dental visits?*
  • Has your Child had any injuries to the teeth, face or mouth*
  • Is there a history of family dental problems?*
  • Do have any dental concerns or questions regarding your Child?
  • Have the previous dental visit with your Child been ?
  • Do any of the following apply to your Child? :

  • During the day, how many cups would your Child drink of:

    Juice: * per day
    Milk:   *  per day
    Fizzy drinks: *  per day   

  • At night time, how many cups would your Child drink of:

    Juice: * at night
    Milk:   *  at night
    Fizzy drinks: *  at night   

  • Rows
  • Consent for Treatment & Communications*
  • Today's Date*
     - -
  • Should be Empty: