Pediatric Dentistry Health History and Patient Information

PEDIATRIC DENTISTRY HEALTH HISTORY AND PATIENT INFORMATION
Child's Legal Name*
Nickname*
Date of Birth*

MonthDayYear
Date
Birth Sex*

MaleFemale
Race / Ethnicity*
Height*
Weight*
Name / Age and relationship of others living in household*
Primary Physician*
Address / Phone*
Last Visit*

MonthDayYear
Date
Medical Specialist
Address / Phone
Last Visit

MonthDayYear
Date
Is your child being treated by a physician at this time?*

YesNo
Reason
Is your child taking any medication (prescription or over the counter), vitamins, or dietary supplements?*

YesNo
List name, dose, frequency & date started:
Has your child ever been hospitalized, had surgery or a significant injury, or been treated in an emergency department?*

YesNo
List date & describe:
Has your child ever had a reaction to or problem with an anesthetic?*

YesNo
Describe:
Has your child ever had a reaction or allergy to an antibiotic, sedative, or other medication?*

YesNo
List:
Is your child allergic to latex or anything else such as metals, acrylic, or dye?*

YesNo
List:
Is your child up to date on immunizations against childhood diseases?*

YesNo
Is your child adopted?*

YesNo
Does he or she know?
Please mark YES if your child has a history of the following conditions. For each “YES”, provide details in the box at the bottom of this list. Mark NO after each line if none of those conditions applies to your child.
Complications before or during birth, prematurity, birth defects, syndromes, or inherited conditions*

YesNo
Problems with physical growth or development*

YesNo
Sinusitis, chronic adenoid/tonsil infections*

YesNo
Sleep apnea/snoring, mouth breathing, or excessive gagging*

YesNo
Congenital heart defect/disease, heart murmur, rheumatic fever, or rheumatic heart disease*

YesNo
Irregular heart beat or high blood pressure*

YesNo
Asthma, reactive airway disease, wheezing, or breathing problems*

YesNo
Cystic fibrosis*

YesNo
Frequent colds or coughs, or pneumonia*

YesNo
Frequent exposure to tobacco smoke*

YesNo
Jaundice, hepatitis, or liver problems*

YesNo
Gastroesophageal/acid reflux disease (GERD), stomach ulcer, or intestinal problems*

YesNo
Lactose intolerance, food allergies, nutritional deficiencies, or dietary restrictions (please list at bottom)*

YesNo
Prolonged diarrhea, unintentional weight loss, concerns with weight, or eating disorder*

YesNo
Bladder or kidney problems*

YesNo
Fine/gross motor deficits, arthritis, limited use of arms or legs, muscle/bone/joint problems, or scoliosis*

YesNo
Rash/hives, eczema, or skin problems*

YesNo
Impaired vision, visual processing, hearing, or speech*

YesNo
Developmental disorders, learning problems/delays, or intellectual disability*

YesNo
Cerebral palsy, brain injury, epilepsy, or convulsions/seizures*

YesNo
Autism/autism spectrum disorder*

YesNo
Recurrent or frequent headaches/migraines, fainting, or dizziness*

YesNo
Hydrocephaly or placement of a shunt (ventriculoperitoneal, ventriculoatrial, ventriculovenous)*

YesNo
Attention deficit/hyperactivity disorder (ADD/ADHD)*

YesNo
Behavioral, emotional, communication, or psychiatric problems/treatment*

YesNo
Abuse (physical, psychological, emotional, or sexual) or neglect*

YesNo
Diabetes, hyperglycemia, or hypoglycemia*

YesNo
Precocious puberty or hormonal problems*

YesNo
Thyroid or pituitary problems*

YesNo
Anemia, sickle cell disease/trait, or blood disorder*

YesNo
Hemophilia, bruising easily, or excessive bleeding*

YesNo
Transfusions or receiving blood products*

YesNo
Cancer, tumor, or other malignancy; chemotherapy, radiation therapy, or bone marrow or organ transplant*

YesNo
Mononucleosis, tuberculosis (TB), scarlet fever, cytomegalovirus (CMV), methicillin resistant staphylococcus aureus (MRSA), sexually transmitted disease (STD), or human immunodeficiency virus (HIV)/AIDS*

YesNo
Please provide details here
Is there any other significant medical history pertaining to this child or his/her family that the dentist should be told?*

YesNo
If YES, describe
What is your primary concern about your child’s oral health?*
How would you describe your child's oral health?*

ExcellentGoodFairPoor
How would you describe your oral health?*

ExcellentGoodFairPoor
How would you describe the oral health of your other children?*

ExcellentGoodFairPoorNot Applicable
Is there a family history of cavities?*

YesNo
If yes, indicate all that apply

MotherFatherBrotherSister
Does your child have a history of any of the following? Please mark any of the following that apply

Inherited dental characteristicsBad breathCavities / decayed teethInjury to teeth, mouth, or jawsJaw joint problems (popping, etc.)Mouth sores or fever blistersBleeding gumsToothacheClinching / grinding his/her teethExcessive gagging
Sucking habit after one year of age*

YesNo
If yes, which?

FingerThumbPacifierOther
For how long?
How often does your child brush his/her teeth?*
Does someone help your child brush?*

YesNo
How often does your child floss his/her teeth?*

NeverOccasionallyDaily
Does someone help your child floss?*

YesNo
What toothpaste does your child use?
What is the source of drinking water at home?*

City/community supplyPrivate WellBottled Water
Do you use a water filter at home?*

YesNo
If YES, type of filtering system
Please check all sources of fluoride your child receives

Drinking waterToothpasteOther-the-counterPrescription rinse/gelPrescription drops/tablets/vitaminsFluoride treatment in the dental officeFluoride varnish by pediatrician/other practitionerOther
Does your child regularly eat 3 meals each day?*

YesNo
Is your child on a special or restricted diet?*

YesNo
If YES, describe
Is your child a "picky" eater?*

YesNo
If YES, describe
Does your child have a diet high in sugar or starches?*

YesNo
If YES, describe
Do you have any concerns regarding your child's weight?*

YesNo
If YES, describe
Please note any other significant dietary habits:
Does your child participate in any sports or similar activities?*

YesNo
If YES, list:
Does your child wear a mouthguard during these activities?*

YesNo
If YES, list:
Has your child been examined or treated by another dentist?*

YesNo
Name of previous dentist:
Date of last visit:

MonthDayYear
Date
Reason for last visit
Were x-rays taken of the teeth or jaw?*

YesNo
Date of most recent dental x-rays

MonthDayYear
Date
Has your child ever had orthodontic treatment (braces, spacers, or other appliances)?*

YesNo
If YES, when?
Has your child ever had a difficult dental appointment?*

YesNo
If YES, describe?
How do you expect your child will respond to dental treatment?*

Very wellFairly wellSomewhat poorlyVery Poorly
Is there anything else we should know before treating your child?*

YesNo
If YES, describe?
SUPPLEMENTAL HISTORY QUESTIONS FOR AN INFANT/ TODDLER (complete if your child is under 3 years old)
Was your child born prematurely?

YesNo
If YES, what week?
What was your child's birth weight?
How long was your child breast-fed?

N/ALess than 6 months6-11 months12-17 months18-23 months2 years or more
How long was your child bottle-fed?

N/ALess than 6 months6-11 months12-17 months18-23 months2 years or more
Do/did you feed your child infant formula?

YesNo
Yes YES, what type (check one)

Ready to usePowderedLiquid concentrate
Does/did your child sleep with a bottle or breastfeed(co-sleep)?

YesNo
If YES, content of bottle?
Does/did your child use a no-spill training cup (sippy cup)

YesNo
If YES, content in sippy cup?
Child's age (in months) when first tooth appeared in months
Has your child experienced any teething problems?

YesNo
When did you begin brushing his/her teeth?

N/ABefore age of 6 months6-11 months12-17 months18-23 months2 years or more
When did you begin using toothpaste?

N/ABefore age of 6 months6-11 months12-17 months18-23 months2 years or more
Who is your child’s primary caretaker during the day?
During the evening?
Name/age of siblings at home
Please Acknowledge the following:
Check the following to acknowledge*

We have the right to charge $30 for any missed, canceled, or rescheduled office visits, exams, and/or cleaning appointments without a 24 hour notice during our normal business hours. ($90 for treatment appointments)Our business hours are Monday - Thursday, 8AM - 5PM (Lunch 1PM - 2PM). Closed Friday - Sunday.Please Note: If you call outside of our normal business hours & reach the answering service, it is an EMERGENCY LINE ONLY. They will not takemessages to make any changes to appointments. Any appointment changes or questions are to be made during our normal business hours.
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Date
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