Pediatric Dentistry of Winchester: Medical History Update Form

Pediatric Dentistry of Winchester: Medical History Update Form

Donna Klein, DMD | 2560 Bypass Road #2, Winchester, KY 40391
Patient's Name*

First NameMiddle NameLast Name
Name of Person Filling Out This Form*

First NameLast Name
Relation to Patient*
Physician's Name*
Physician's Phone Number*
Please enter a valid phone number.
Is your child in good health?*

YesNo
Has your child had surgery/hospitalizations? Please give reason and date:*

NoYes
Is your child taking any medications? Please give medication and reason:*

NoYes
Is your child allergic to any medications? If yes, please list them:*

NoYes
Is your child allergic to anything (latex, milk, grass, etc...)? If yes, please list allergies.*

NoYes
Are your child's immunizations up to date?

YesNo

Please check if your child currently has or formerly had any of the following:*

	Has/Had	Never
Abnormal Bleeding/Hemophilia
Acid Reflux
ADD/ADHD
Anemia
Apraxia/Speech Disorder
Artificial Heart Valve
Asthma/Breathing Problems
Autism/Asperger's/PDD
Blood Transfusion
Cancer
Cerebral Palsy
Cleft Lip/Palate
Cold Sores
Congenital Heart Condition
Depression/Mental Health Disorders
Diabetes
Down Syndrome
Dry Mouth
Eating Disorder
Epilepsy/Seizures/Neurological disorders
Epinephrine Sensitivity
Fetal Alcohol Syndrome
GERD/Acid Reflux
Hearing impairment
Handicaps/Disabilities
Heart Murmur
Hepatitis
High Blood Pressure
HIV/AIDS
Hyperthyroidism
Hypothyroidism
Kidney/Liver Condition
Leukemia
Low Blood Pressure
Lymphoma
Latex Allergy
Metabolic Disorder
Migraines/Headaches
Operations/Hospital Stays
Organ Transplant
Premature Birth
Pre-med for Heart Condition
Radiation Therapy
Rheumatic Fever
Seasonal Allergies
Sleep Apnea
Stroke
TMJ Disorder
Tuberculosis
Ulcers
Vision Problems
Vitamin Deficiency

If your child has a different condition not listed above, please name that here:
Is today your child's first visit?*

YesNo
Name of previous dentist:
Date of last visit/x-rays:

MonthDayYear
Date
Has your child had any unfavorable dental experiences? If so, please explain.*

NoYes
Has your child ever had injury to his/her face or mouth? If so, when and how?*

NoYes
How often does your child brush his/her teeth?*
How often does your child floss?*
Does someone help?*

YesNo
Does your child use a fluoridated toothpaste?*

YesNo
Is your home water fluoridated?*

YesNo
Does your child drink milk/soda/juice between meals?*

YesNo
Does your child eat frequent snacks between meals?*

YesNo
Are there any mouth habits?

BottleBreastfeedingPacifierSippy CupFinger/Thumb SuckingTooth GrindingTongue ThrustMouth Breathing
I hereby acknowledge that the information provided above is a true representation of my child's medical and dental history/condition.
Parent's/Guardian's Signature:*

Clear
Date*

MonthDayYear
Date
Should be Empty: