DENTAL & MEDICAL HISTORY

  • Patient Medical History

  • Child's Birthdate*
     / /

  • DENTAL HISTORY

  • Is the child currently in pain?*
  • Has the child experienced problems with previous dental work?*
  • Does the child brush his/her teeth daily?*
  • Floss his/her teeth daily?*
  • Has the child had sealants in the past?*
  • Date of Last Visit
     / /
  • Is this Dentist your :

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

  • Lip sucking/Biting*
  • Clenching/Grinding Teeth*
  • Tongue/Cheek Biting*
  • Mouth Breather*
  • Nail Biting*
  • Thumb/Finger Sucking*
  • Used Pacifier*
  • Speech Problems*
  • Chewing on Objects*
  • Nursing Bottle Habits*
  • Tongue Thrust*
  • Breast Fed*

  • MEDICAL HISTORY

  • Format: (000) 000-0000.
  • Date of Last Visit*
     / /
  • Is the child currently under the care of a physician?*
  • Please describe the child's current physical health:*
  • Are immunizations current?*
  • Is the child currently allergic to any of the following*
  • Does your child have any medical conditions that require Pre-Med?*

  • Has the child had/experienced any of the following?

  • Abnormal Bleeding*
  • Down Syndrome*
  • Radiation Therapy*
  • Anemia*
  • Emotional/Psychiatric Problems*
  • Rheumatic Fever*
  • Any Hospital Stays/Operations*
  • Epilepsy*
  • Seizures*
  • Asthma*
  • Food Allergies*
  • Seasonal Allergies*
  • Autism Spectrum*
  • G-Tube Feeding*
  • Sickle Cell Anemia*
  • Birth Defects*
  • Hearing Loss/Impairment*
  • Skin Disorders*
  • Blood Transfusions*
  • Heart Condition/Murmur*
  • Sleep Apnea/Snoring*
  • Cancer*
  • Hepatitis*
  • Spina Bifida*
  • Cerebral Palsy*
  • HIV/AIDS*
  • Tonsililtis*
  • Chronic Ear Infections/Tubes*
  • Hyperactivity/ADHD*
  • Tuberculosis (TB)*
  • Cystic Fibrosis*
  • Kidney Disease*
  • Tumors*
  • Delayed Speech Development*
  • Learning Disabilities*
  • Syndrome (specify)*
  • Developmental Delay*
  • LIver Disease*
  • Diabetes*
  • Muscular Dystrophy*

  • AUTHORIZATION

  • 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.

  • Date*
     / /
  •  
  • Should be Empty: