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.Format: (000) 000-0000.
Is your child in good health?
Has your child had surgery/hospitalizations? Please give reason and date:

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

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

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

Yes
Are your child's immunizations up to date?

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

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

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

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

Yes
How often does your child brush his/her teeth?
How often does your child floss?
Does someone help?
Does your child use a fluoridated toothpaste?
Is your home water fluoridated?
Does your child drink milk/soda/juice between meals?
Does your child eat frequent snacks between meals?
Are there any mouth habits?
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:
Date

MonthDayYear
Date
Should be Empty: