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)
YesNo
If yes please list what and when
YesNo
If yes please list what and when
YesNo
If yes please list what and when
YesNo
If yes please list what and when
YesNo
If yes please list what and when
YesNo
If yes please list what and when
YesNo
If yes please list what and when
YesNo
If yes please list what and when
Name and phone number of your child's physician:
AIDS/HIV PositiveADHD/ADDArthritisAsthmaAutismBlood ProblemsBronchitisCancerCerebral PalsyDiabetesDown syndromeEar InfectionEmotional ProblemsEndocrine ProblemsEpilepsy/SeizuresEye ProblemsHearing ProblemsHepatitis A/B/CLiver/Kidney DiseaseLeukemiaProlonged BleedingRheumatic FeverSpeech ProblemsTonsillitisTuberculosisThyroid Disease
DENTAL HISTORY
Main reason for today's visit?
1x/day2x/dayEvery other dayNot regularly
1x/dayEvery other day1x/weekNot regularly
ParentChildHalf/halfNone
RX by MD/DMDIn H20ToothpasteRinseNone
6 mo12 mo24 moStill use
ExcellentGoodFairPoorDon't know
ExcellentGoodFairPoorDon't know
LowAverageHigh
Thumb/fingerBinkyMouth breatherGrinding
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