Slone Dental - Pediatric Form

Slone Dental - Pediatric Form
Patient's Name*

First NameLast Name
Nickname
Date of Birth*

MonthDayYear
Date
Age
Sex
Child's Physician
Last Date Seen

MonthDayYear
Date
Immunizations up to date?*

YesNo
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
1. Condition of your child's health:
2. Has your child recently undergone or is he/she undergoing any medical treatment?*

YesNo
3. Has your child ever been hospitalized, had an operation or been confined to bed for a long period of time?*

YesNo
4. Is any medical treatment anticipated for the future?*

YesNo
5. Does your child have any allergic reactions to any kind of medicine, latex, or food?*

YesNo
6. Is your child presently taking any kind of medication?*

YesNo
7. Does your child have any unusual fevers?*

YesNo
8. Does your child have any history of: (check all that apply)

AllergiesCancerDown SyndromeDiabetesHIV/AIDSAnemiaSickle Cell AnemiaRheumatic FeverBrain InjuryADD/ADHDExcessive BleedingCerebral PalsyHemophiliaLiver DiseaseHepatitisKidney ProblemsHigh Blood PressureMental/EmotionalProblemsAutism/AspergersAsthmaEpilepsy/SeizureHeart MurmurTuberculosisHeart Disease
9. Has your child ever had any hearing, sight, speech or coordination problems?*

YesNo
10. Is there any additional medical information we should know?*

YesNo
11. Is this the first time your child has visited a dental office?*

YesNo
12. If your child has previously been to the dentist, did he/she receive any of the following:

local anestheticxrayssedationnitrous oxide analgesic (laughing gas)general anesthetic
Were there any unfavorable reactions?
13. Were there any acute dietary or medical problems during pregnancy such as: measles, sickness with high fever, blood disorders (anemia), others? (Please skip this question if your child was adopted)

YesNo
14. Does your child have a history of:

Thumb suckingTongue thrustingLip or nail bitingPacifierMouth breathingObject biting
15. Has there been any injury to your child's teeth by fall, blow, bump, or otherwise? If yes, please explain.

NoYes
16. Up to what age was your child using the night bottle or breastfed?
17. Does your child use a sippy cup?*

YesNo
18. How often does your child brush his/her teeth?
19. Does your child consume excessive amounts of any of the following:

Milk JuiceCandyWell waterBottled waterSoda
20. Is your child receiving fluoride supplements?*

YesNo
21. Does your child drink?

City waterWell waterBottled waterFiltered water
22. Has your child ever complained of:

ToothacheJaw sounds/painFrequent headachesTeeth sensitive to heatTeeth sensitive to coldPain in ears
23. Are you concerned about any special dental problems now?
24. Reason for seeking treatment at this time?
25. Do you expect your child to be uncooperative? If yes please explain:
Thank you for completing this personal history. The information which you supplied allows us to plan for your child's emotional and dental needs while making a thorough evaluation of his/her dental health.

The above statements are, to be best of my knowledge, true and correct. I authorize the treatment of this patient.
Signature of Parent or Guardian*

Clear
Date*

MonthDayYear
Date
Relationship to Patient*
Should be Empty: