Medical History

Medical History
Although dentistry deals primarily with teeth and its surrounding structures, the oral cavity is a part of the entire body. Health problems that your child may have, or medications that your child may be taking could have an important interaction with dentistry your child may receive. Thank you for answering the following questions thoroughly.
Patient's name

First NameLast Name
Age
Date of Birth

MonthDayYear
Date
M / F
MEDICAL HISTORY(If yes please list what and when)
Is your child taking any medications?
If yes please list what and when
Is your child allergic to any medications / food / latex?
If yes please list what and when
Any problems / complications during pregnancy / delivery?
If yes please list what and when
Does your child have any health problems?
If yes please list what and when
Has your child been diagnosed with any medical conditions?
If yes please list what and when
Has your child ever been hospitalized?
If yes please list what and when
Has your child ever had surgery?
If yes please list what and when
Are your child's immunizations up to date?
If yes please list what and when
Name and phone number of your child's physician:
Check any of the following for which your child has been diagnosed:
DENTAL HISTORY
Main reason for today's visit?
How often are the child's teeth brushed
How often are the child's teeth being flossed?
Who does the brushing/flossing?
Fluoride use?
When was your child weaned off nursing/bottle?
How would you rate mother's oral health?
How would you rate father's oral health?
How would you rate child's sugar consumption? (candy, juice, etc)
Does your child have any oral habits?
History of dental trauma? Yes / No - If yes please explain
Is there any additional medical/dental information you may want the doctors to know?
Parent/Guardian signature:
Relationship to patient:
Date:

MonthDayYear
Date
Should be Empty:

Medical History

MEDICAL HISTORY(If yes please list what and when)

DENTAL HISTORY