Slone Dental - Pediatric Form

Patient's Name

First NameLast Name

Nickname

Date of Birth

Date

Age

Sex

Child's Physician

Last Date Seen

Date

Immunizations up to date?

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?

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

4. Is any medical treatment anticipated for the future?

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

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

7. Does your child have any unusual fevers?

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

9. Has your child ever had any hearing, sight, speech or coordination problems?

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

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

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

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)

14. Does your child have a history of:

15. Has there been any injury to your child's teeth by fall, blow, bump, or otherwise? If yes, please explain.

Yes

16. Up to what age was your child using the night bottle or breastfed?

17. Does your child use a sippy cup?

18. How often does your child brush his/her teeth?

19. Does your child consume excessive amounts of any of the following:

20. Is your child receiving fluoride supplements?

21. Does your child drink?

22. Has your child ever complained of:

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

Date

Relationship to Patient