DENTAL & MEDICAL HISTORY

First*

M.I.*

Last*

Child's Birthdate*

Date

Is the child currently in pain?*

YESNO

What is the primary reason for today's visit?

Has the child experienced problems with previous dental work?*

YESNO

Does the child brush his/her teeth daily?*

YESNO

Floss his/her teeth daily?*

YESNO

Has the child had sealants in the past?*

YESNO

What is the date of the last dental x-ray?

What is the name of the last Dentist you have seen? *

Date of Last Visit

Date

What is the Dentist's phone number?

Is this Dentist your :

Previous DentistCurrent Dentist

Why did you leave your previous dentist? *

What did you like most about any dentist you have seen? *

What did you dislike about any dentist you have seen?

How do you think your child will do today? *

Does/did the child have any of the following habits?

Lip sucking/Biting*

YESNO

Clenching/Grinding Teeth*

YESNO

Tongue/Cheek Biting*

YESNO

Mouth Breather*

YESNO

Nail Biting*

YESNO

Thumb/Finger Sucking*

YESNO

Used Pacifier*

YESNO

Speech Problems*

YESNO

Chewing on Objects*

YESNO

Nursing Bottle Habits*

YESNO

Tongue Thrust*

YESNO

Breast Fed*

YESNO

Child's Physician*

Phone #

Date of Last Visit*

Date

Address of Physician

Is the child currently under the care of a physician?*

YESNO

If yes, please explain:

Please describe the child's current physical health:*

GoodFairPoor

Are immunizations current?*

YESNO

Please list all of the drugs that the child is currently taking:

Is the child currently allergic to any of the following*

Does your child have any medical conditions that require Pre-Med?*

YESNO

Has the child had/experienced any of the following?

Abnormal Bleeding*

YESNO

Down Syndrome*

YESNO

Radiation Therapy*

YESNO

Anemia*

YESNO

Emotional/Psychiatric Problems*

YESNO

Rheumatic Fever*

YESNO

Any Hospital Stays/Operations*

YESNO

Epilepsy*

YESNO

Seizures*

YESNO

Asthma*

YESNO

Food Allergies*

YESNO

Seasonal Allergies*

YESNO

Autism Spectrum*

YESNO

G-Tube Feeding*

YESNO

Sickle Cell Anemia*

YESNO

Birth Defects*

YESNO

Hearing Loss/Impairment*

YESNO

Skin Disorders*

YESNO

Blood Transfusions*

YESNO

Heart Condition/Murmur*

YESNO

Sleep Apnea/Snoring*

YESNO

Cancer*

YESNO

Hepatitis*

YESNO

Spina Bifida*

YESNO

Cerebral Palsy*

YESNO

HIV/AIDS*

YESNO

Tonsililtis*

YESNO

Chronic Ear Infections/Tubes*

YESNO

Hyperactivity/ADHD*

YESNO

Tuberculosis (TB)*

YESNO

Cystic Fibrosis*

YESNO

Kidney Disease*

YESNO

Tumors*

YESNO

Delayed Speech Development*

YESNO

Learning Disabilities*

YESNO

Syndrome (specify)*

YESNO

Developmental Delay*

YESNO

LIver Disease*

YESNO

Diabetes*

YESNO

Muscular Dystrophy*

YESNO

Please explain any Yes answers:

I affirm that the information I have given is correct to the best of my knowledge, and that it is my responsibility to inform this office of any changes in my child's medical status. I authorize the dental staff to perform the necessary services that my child may need.

Signature*

Date*

Date

Printed Name*

Patient Medical History

DENTAL HISTORY

MEDICAL HISTORY

AUTHORIZATION