Medical and Dental History

MEDICAL AND DENTAL HISTORY

Great Lakes Pediatric Dentistry
MEDICAL HISTORY
Child's Legal Name (First Last)
Date of Birth

MonthDayYear
Date
Describe your child's overall health:

GoodFairPoor
Is your child under the care of a Physician?

YesNo
Doctor's Name:
Doctor's Phone Number
Please enter a valid phone number.
Does your child have any allergies?

YesNo
Please list allergies below:
Is your child taking any medication?

YesNo
Please list medications including: prescription or over the counter), vitamins, or dietary supplements:
Select any that apply. If yes please explain.

Abuse (physical, psychological, emotional, or sexual) or neglectAbdominal BleedingAllergy to antibioticsAllergic to sedative medicationsAllergic to latexAllergic to metals, acrylic, or dyeAllergic to tree nutsAllergic to any other foodsADD/ADHD Attention deficit/hyperactivity disorderAnemia, sickle cell disease/trait, or blood disorderAny Hospital Stay or SurgeriesAsthma, reactive airway disease, wheezing, or breathing problemsBehavioral, emotional, communication, or psychiatric problems/treatmentCancer, tumor, or other malignancy; chemotherapy, radiation therapy, or bone marrow or organ transplantChicken PoxComplications before or at birth, prematurity, inherited conditions, syndromes, or birth defects (such as cleft lip/palate)Congenital Heart Defect/disease, heart murmur, rheumatic fever, or rheumatic heart disease
Cystic fibrosisDevelopmental disorders, learning problems/delays, or intellectual disabilityDiabetes Type I, hyperglycemia, or hypoglycemiaDiabetes Type II, or hyperglycemia, or hypoglycemiaEpilepsy or Convulsions/SeizuresEczema, Rash/hives, or skin problemsExposed to HIV, but Neg.Gastroesophageal/acid reflux disease (GERD), stomach ulcer, or intestinal problemsHandicaps/DisabilitiesHearing ImpairmentHeart MurmurHemophilia, bruising easily, or excessive bleedingHepatitisHigh Blood PressureHives(HIV)/AIDS, methicillin- resistant staphylococcus aureus (MRSA), mononucleosis, scarlet fever, sexually-transmitted disease (STD), or tuberculosis (TB)Hydrocephaly or placement of a shunt (ventriculoperitoneal, ventriculoatrial, ventriculovenous)
Impaired vision, visual processing, hearing, or speechJaundice, hepatitis, or liver problemsKidney Disease or bladder problemsLearning DisabilityLow Blood PressureMeaslesMononucleosisMy child needs antibiotics or another medicine before dental treatment.My child IS NOT up to date on immunizations (vaccines).Reactions to Local Anesthetic (Novocain)Rheumatic FeverSinusitis, chronic adenoid/tonsil infectionsSleep apnea, snoring, or mouth breathingScarlet FeverSkin RashThyroid or pituitary problemsTuberculosis (TB)There is something else I would like to tell the Doctor in private.Other
Please explain any of the checked boxes above. Also feel free to tell us anything else you would like use to know below:
DENTAL HISTORY
Is your child in dental pain?

YesNo
What is the primary reason for your visit today?
Please check all that apply:

AbscessBad BreathBrest FedBleeding GumsBrushes teeth once daily supervisedBrushes teeth twice daily supervisedBrushes teeth once daily aloneBrushes teeth twice daily aloneCavities/Decayed TeethChild’s primary drinking water is NOT fluoridatedChewing on objects
Clenching / Grinding teethExcessive GaggingFlosses once dailyInherited Dental CharacteristicsLip Sucking / BitingMouth BreatherMouth sores or blistersMy child has had a traumatizing experience at another dentistMy child has experienced an injury to the mouth, teeth or JawMy child is currently taking fluoride supplementsMy child DOES NOT use a fluoride toothpaste at home
Nail BitingNursing Bottle HabitsSpeech ProblemsToothacheThumb / Finger SuckingTongue / Cheek BitingTongue ThrustTMD/TMJ SymptomsUsed/Uses a PacifierWe are a fluoride-free family
Please explain any of the checked boxes above. Also feel free to tell us anything else you would like use to know below:
I affirm that the information I have given is correct to the best of my knowledge. It will be held in the strictest confidence and it is my responsibility to inform the office of any changes in my child’s medical status. I authorize the dental stay to perform the necessary dental services my child may need. As a parent or guardian who accompanies the child, I am responsible for payment at time of services unless prior arrangements have been approved.
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MEDICAL AND DENTAL HISTORY

MEDICAL HISTORY

DENTAL HISTORY