Medical and Dental History

Dental/Medical History

CHILD'S INFORMATION

Child's Name

Child's DOB

Your child's health, as well as any medications which your child takes, can have an interrelationship with the dental care you child receives.
Please answer each question completely.

How often does your child brush?

How often does your child floss?

Does your child:

Take fluoride supplements

Yes No

Use a pacifier

Yes No

Suck thumb or finger

Yes No

Bite or chew nails

Yes No

Grind teeth

Yes No

Clench jaws

Yes No

Was your child breast fed?

Yes No

Age breast-feeding was discontinued:

Was your child bottle fed?

Yes No

Age bottle feeding was discontinued?

Has your child ever had the following (please check if any of the below apply)

Click for No to All

Asthma

Yes No

Autisum

Yes No

Anemia

Yes No

ADHD

Yes No

Bleeding Problems

Yes No

Brain Injury

Yes No

Cancer

Yes No

Cerebral Palsy

Yes No

Convulsion/Seizures

Yes No

Cystic Fibrosis

Yes No

Developmentally Delayed

Yes No

Diabetes

Yes No

Eye Problems

Yes No

Hearing Loss

Yes No

Heart Murmur

Yes No

Hepatitis

Yes No

HIV (AIDS)

Yes No

Jaundice

Yes No

Kidney Problems

Yes No

Leukemia

Yes No

Measles

Yes No

Mental Disability

Yes No

Orthopedic Problems

Yes No

Otitis

Yes No

Pneumonia

Yes No

Rheumatic Fever

Yes No

Scarlet Fever

Yes No

Please list any other relevant Medical or Dental conditions

Current medications taken

Allergies or adverse reactions to any medications (penicillin, sulfas)

Allergies to any substances (e.g. latex):

Previous hospitalizations, surgeries, or serious illnesses with dates

Is there anything specific you would like to discuss with Doctor today?

Date of last dental visit

Previous dentist

Child's pediatrician

Phone number

Authorization and Release

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can put my child's health at risk and that it is my responsibility to inform the dental office of any changes in my child's medical status. I authorize the dental staff to perform the necessary dental services that my child may need. I also authorize the dentist to release any information including the diagnosis and the records of treatment or examination rendered to my child during the period of such care to third party payers and/or other health practitioners as necessary. I further acknowledge the receipt of the Dental Materials Fact Sheet and HIPAA Privacy Form.

E-mail Address

Signed By

Phone Number

Date

Signature

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